Definition, positive CBT, effectiveness, CBT sessions, qualifications, benefits, limitations, cultural diversity, practice approach, CBT sources, CBT types, online CBT, Session rating scale
Six sections follow:
Background Material that provides the context for the topic
A suggested Practice Approach
A list of Supporting Material / References
Appendix 1: Theories underpinning CBT
Appendix 2: Types of CBT
Appendix 3: Online CBT
Appendix 4: Session rating scale
Feedback welcome!
Background Material
What is Cognitive Behavioural Therapy?
The idea behind cognitive behavioural therapy (CBT) is that if you change the way you think, you can change the way you feel and behave (Tomlinson & Tomlinson, 2011). An explanation of the theories and therapies that underpin CBT is located in Appendix 1.
Cognitive behavioural psychology developed in response to growing discontent with a strictly behavioural focus in psychology together with dissatisfaction with psychoanalytic models that emphasised unconscious processing, long-term therapy and non-directive intervention. Cognitive behaviourists discarded the simplistic notion that people were merely passive responders to stimuli. Rather, individuals are seen as proactive, autonomous agents who are capable of influencing their environments through identifying and modifying problematic or distorted thinking patterns. The CBT model emphasises that it is not the situation that causes the emotional distress that an individual experiences. CBT argues that it is the individual’s interpretation of that situation which causes the emotional distress. CBT works by focusing on negative thoughts and learning how to challenge them, as well as learning how to change unhelpful emotions and behaviours (AACBT, 2015; Connolly & Healy, 2009; HEPMHCS, 2010, Leahy, 2009; Morley, 2015; Payne, 2014).
For example, Leahy (1997) provides a list of 17 harmful thoughts that CBT can assist people to overcome, e.g.
Mind reading: You assume that you know what people think without having sufficient evidence of their thoughts. "He thinks I'm a loser."
Catastrophizing: You believe that what has happened or will happen will be so awful and unbearable that you won't be able to stand it. "It would be terrible if I failed."
Labelling: You assign global negative traits to yourself and others. "I'm undesirable" or "He's a rotten person.”
Overgeneralizing: You perceive a global pattern of negatives on the basis of a single incident. "This generally happens to me. I seem to fail at a lot of things."
At the conclusion of their discussion on CBT Tomlinson and Tomlinson (2011) describe CBT as follows.
CBT is action oriented and leans heavily on an educative focus for client changes.
The focus is on behaviour and/or cognitive change, or both, and generally requires a structured approach to change by both client and therapist.
The approach is not a “quick fix” for complex problems. It relies on behaviour analysis and the systematic use of behavioural techniques essential for successful behavioural change.
Behaviour therapies are made up of numerous theories of behaviour with an array of interventions, strategies, and techniques. Matching technique to problem is essential.
Cognitive behavioural techniques depend on relationship development, and sensitivity to the client’s needs.
A simple example of how CBT works
CBT aims to stop negative thoughts and cycles such as those on the left by breaking down things that make a person feel bad, anxious or scared. By making problems more manageable, CBT can help change negative thought patterns and improve the way people feel. CBT can help people get to a point where they can achieve this without the help of a therapist (Blenkiron, 2022; NHS, 2019; Teater, 2013).
CBT is continually evolving. The table in Appendix 2 lists eleven therapy types that come under the CBT umbrella.
Positive CBT (P-CBT)
While the CBT model focuses on the problem, what causes the problem, and possible interventions for the problem, positive CBT shifts therapy towards focusing on what is right with a person and on what is working, instead of focusing on all the problems a person faces and what is not working. The CBT concept of seeking to understand thoughts, feelings and behaviour also applies to P-CBT, but the focus shifts from what is going wrong to where things are going well (Bannink, 2017). Geschwind et al. describe P-CBT as having three ingredients:
(1) the structure of CBT (e.g., clear session structure, homework, self-monitoring and functional analyses (but of better moments instead of the problem),
(2) the content and language of solution-focused brief therapy (e.g., patient as co-expert, focus on the patient's preferred future and better moments), and
(3) positive psychology exercises (e.g., three blessings, optimistic attribution).
Geschwind et al. conducted a randomized controlled trial to compare P-CBT with traditional CBT finding both approaches improved participant’s depression, but P-CBT delivered a stronger improvement.
Positive CBT helps people identify positive thoughts that lead to helpful and beneficial actions, to consciously choose constructive thoughts, helping them respond more positively and appropriately to a particular situation. One can consider positive CBT as extending the A-B-C model to the A-B-C-D-E model developed by Albert Ellis in the 1950s. (The A-B-C model is explained in more detail in Appendix 1). In Ellis’ extension of the model ‘Disputation of the beliefs’ and ‘Effective new approach’ are added to Antecedents, Behaviour and Consequence. During the disputation stage people are supported/challenged to demonstrate how some of their beliefs are inaccurate and establish more rational beliefs. In the fifth stage people are supported to replace their previous beliefs with more realistic, positive beliefs, based on the results of the disputation stage (Harms, 2007; Sugay, 2021). In helping people generate solutions and possibilities, therapists often use solution-focused therapy techniques (Bannick, 2017; Reichel, 2021), a topic covered in detail elsewhere on this website (https://www.thesocialworkgraduate.com/post/practice-model-solution-focused-approach)
Positive CBT is grounded in a strengths-based approach (Bannick, 2017; Reichel, 2021); making it a good fit for use by social workers whose practice is often founded on such an approach. People are encouraged to work with the therapist to explore strengths and how they can be applied in life. The strengths-based approach is the foundation of the ‘upward arrow technique’ of positive CBT (Bannick, 2017; Reichel, 2021). Traditional CBT uses a ‘downward arrow technique’ focusing on “What’s bad about that?” “What’s not working?” “What’s not helping?”, and “What is the worst thing that can happen?” The upward arow technique focuses on the person’s positive thoughts and assists in finding exceptions to the problem: “What would you like to change?” “How will you feel once that situation changes?” “What difference will that make in your life or your situations?”, and “What is the best-case scenario?” (Sugay, 2021).
Effectiveness
Numerous randomised controlled trials have demonstrated the effectiveness of CBT (Pease, 2009; Thomlison & Thomlison, 2011).
CBT is a first choice treatment for:
Anxiety (e.g. generalised anxiety disorder or panic disorder) and depression, where it works as well as antidepressants for treating many forms of depression. It may work slightly better than antidepressants in treating anxiety.
Phobias and obsessive-compulsive therapy, where it is the most effective psychological treatment (AACBT, 2015; Blenkiron, 2022).
For several mental health problems, adding CBT to medication may be more effective than medication on its own, or CBT on its own (Blenkiron, 2022).
Overall, CBT has been shown to be effective in these areas: Depression, anxiety, panic, phobias, eating disorders, obsessive compulsive disorder, post-traumatic stress disorder, bipolar disorder, psychosis, sleep difficulties, stress, anger, low self-esteem, pain, extreme tiredness, sexual dysfunction, couples’ problems, child behaviour problems, borderline personality disorder, schizophrenia, alcohol misuse (AACBT, 2015; Blenkiron, 2022; NHS, 2019; Teater, 2013, Tomlinson & Tomlinson, 2011).
CBT Sessions
CBT can be carried out with a therapist in 1-to-1 sessions or in groups with other people who have similar issues. Individual CBT therapy usually involves meeting with a CBT therapist for between 5 and 20 weekly or fortnightly sessions, with each session lasting 30 to 60 minutes (Blenkiron, 2022; NSH, 2019).
CBT therapists should have substantial training and experience in the approach (AACBT, 2015; NHS, 2019; Tomlinson & Tomlinson, 2011). Payne (2014) states CBT is a technical procedure, with much jargon and many formal procedures, apparently worked out in set systems. Procedures are often ‘manualized’, giving guidance to inexperience practitioners. The danger is that less experienced practitioners with fewer qualifications and little or no supervision will simply follow manuals rather than build up skills they need to use CBT flexibly. Where practitioners have a good level of training, support and experience in CBT, they are able to use the methods more flexibly.
Benefits
Behaviour therapy has been demonstrated to be effective in most areas of social work practice. Behaviour therapy as an effective therapeutic intervention is well established, and it can be argued that behaviour theory is the most advisable therapeutic option. CBT will be invaluable to social workers in every practice situation, with the most common behavioural therapy techniques used by social workers being:
Cognitive behavioural procedures such as cognitive restructuring, self-instructional training, thought stopping, and stress inoculation training.
Assertiveness training, which improves communication skills in personal, work and other relations: how to express rights, requests, opinion, and feelings, honestly and directly through body language and self-awareness.
Systematic desensitization and variants of this procedure such as eye movement desensitization, procedures involving strong anxiety evocation (e.g. flooding, paradoxical intention), operant-conditioning methods (e.g. extinction, positive or negative reinforcement).
Aversion therapy: inducing dislike to the problem behaviour (Tomlinson & Tomlinson, 2011).
Some of the other advantages of CBT include:
it may be helpful in cases where medicine alone has not worked,
it can be completed in a relatively short period of time compared with other talking therapies,
the highly structured nature of CBT means it can be provided in different formats, including in groups, self-help books and online,
it teaches people useful and practical strategies that can be used in everyday life, even after the treatment has finished. (NHS, 2019)
Limitations
Attending regular CBT sessions and carrying out any extra work between sessions can be time-consuming.
CBT may not be suitable for people with more complex mental health needs or learning difficulties, as it requires structured sessions.
CBT involves confronting emotions and anxieties; as a result people may experience initial periods where they are anxious or emotionally uncomfortable.
CBT focuses on the person's capacity to change their thoughts, feelings and behaviours – this does not address any wider problems in systems or families that often have a significant impact on someone's health and wellbeing, such as an unhappy childhood. CBT tends to ignore social and structural inequalities that underly some mental health conditions, even though the outer world is where the real agenda lies. On the other hand, Harms (2007) suggests there is nothing preventing a social worker helping clients engage in larger system change activities even though nothing within the theory encourages these interventions.
Cultural influences, and their impact on thought patterns and beliefs receive limited attention in CBT (Connolly & Healy, 2009; Harms; 2007; NHS, 2019; Teater, 2013)
Cultural Diversity and CBT
Culture, by its very nature, influences behavioural outcomes and cognitions. Due to the growing diversity among populations, social workers are more and more likely to work with clients of diverse backgrounds. Therefore it is increasingly important to understand the relevance of culture and the applicability of treatment methods across diverse groups (Muroff, 2012).
Cognitive behavioural therapy (CBT), like most modern psychotherapies, is underpinned by European-American values. CBT research until recently has primarily focused on white, middle-class, well-educated service users, who are of European-American identities. Theories of CBT are primarily a Western model of practice since they emphasize the psychological change of individuals, rather than the broader social groupings that might be more relevant in developing countries; they also use a Western model of scientific method, which is less influential in many Eastern countries (Payne, 2014; Tomlinson & Tomlinson, 2011).
Culturally adapting CBT is the only way access to this evidence-based therapy can be improved for marginalized communities in Europe, North America and other Western-tradition countries and for the local population outside of these regions where more than 80% of the world population lives. This cultural adaptation is occurring, as noted in the 2019 edition of The Cognitive Behaviour Therapist, where a variety of approaches to culturally adapting CBT are presented (Naeem, 2019; Tomlinson & Tomlinson, 2011).
CBT has a number of strengths that, if used appropriately, make it useful across diverse populations. A critical aspect is its ongoing collaborative and inclusive focus, that places significant value on the client’s viewpoints and outlook. It emphasizes continuous assessment and documentation throughout the therapeutic process. These recurrent assessments provide an opportunity to consider and incorporate the client’s cultural context and experiences (Muroff, 2012; Teater, 2013).
Rathod, Phiri and Naeem (2019) suggest the Triple-A Principle for promoting cultural adaptation of CBT.
Ensure the clinician is aware of relevant cultural issues as part of preparation for therapy.
Conduct appropriate assessment and engagement with the person.
Adjust therapy based on cultural awareness.
Awareness raising can occur through books, film, lectures and attending community events. It can also occur through adopting an open, exploratory mind during initial sessions, where questions can be asked about values, beliefs, coping strategies and connections to cultural groups. Cultural assumptions can be explored, as well as clarifying verbal and nonverbal communication approaches, e.g. the level of eye contact, facial expression, posture, gestures (Muroff, 2012).
Assessment can take this cultural exploration further by identifying people’s strengths and assets, including problem-solving capacity and approaches as well as ability and methods of managing stress. Is the person spiritual or religious? Do community and social networks exist? What is their level of influence on the person? Determining how clients identify culturally during the assessment process may preclude erroneous assumptions, prompt more client disclosure, and convey the clinician’s openness. (Muroff, 2012).
When adjusting therapy, clinicians and clients should work together to choose stimuli that are culturally relevant and appropriate and incorporate individuals that are part of the person’s social network. For example, assertiveness could be dangerous in some environmental conditions. In some cultures, family may be critical to therapeutic success. Finally, it is critical that traditional methods of healing are treated with respect and not condemned (Muroff, 2012).
Practice Approach
This section outlines the ‘traditional’ CBT process and then the ‘positive’ CBT approach. The aim is to provide a guide to the overall structure of CBT; some of what follows may be useful as a resource for social workers to incorporate into their practice but is not intended to be a comprehensive outline of the CBT approach. As mentioned in the section on ‘CBT Sessions’ above, competent CBT practitioners will have undergone extensive study in the area. However, being aware of the CBT approach and some of the tools used by CBT therapists can also influence social work practice. In fact, positive CBT, and its use of solution-focused questions, demonstrates the potential relevance of CBT for social workers.
The Therapist Aid at (https://www.therapistaid.com then search for “CBT”) provides a number of practical resources and information that may be useful to incorporate into social work practice. These include
The cognitive triangle
Challenging negative thoughts
The cognitive model example sheet
The cognitive model practice exercises
The cognitive behaviour model
Cognitive distortions
Core beliefs
There are also a number of online CBT resources for people in the community to access. See Appendix 3.
As outlined in the Background Material above CBT believes creating change in any of the domains of thoughts, feelings or behaviours will result in change in the other domains. This is sometimes referred to as the ‘Think-Feel-Do’ framework (Harms, 2007). Payne (2014) suggests CBT operates from three principles:
All of our thinking is knowable to us; nothing is hidden as unconscious
Our rational minds manage our emotional responses; we do not have solely emotional responses to life experiences
Since our thoughts are knowable and control our reactions to events, we must be able to modify our reactions to what happens to us through using cognitive strategies.
CBT was evolved into an equation or theory of change by Ellis in 1995: A + B = C D E, where A denotes an activating event or circumstance; B denotes beliefs (rational or irrational) and C denotes the consequences in terms of thoughts, feelings and behaviours. D is the disputation of beliefs and emotions and the attempts to establish more rational beliefs in lieu of irrational ones. Implementing E (the effective new approach) leads to meaningful change in C (consequences) (Harms 2007).
An Approach to Use with ‘Traditional’ CBT
The implementation of CBT in practice involves three stages: assessment, intervention and evaluation (Teater, 2013).
1. Assessment consists of exploring jointly with service users how their thoughts, feelings and behaviours are contributing to the presenting problem in terms of frequency, intensity and duration, i.e. the A-B-C model (Teater, 2013). HEPMHCS (2010) suggests having a person complete a ‘hot cross bun’ can assist in this.
2. The assessment stage will inform the type of intervention to be selected, based on the thoughts, feelings or behaviours that are the focus of change (Teater, 3013), the ‘D’ and ‘E’ of the Ellis model.
Prior to implementing interventions Payne (2014) suggests developing a case formulation. People have certain core beliefs, assumptions and schemas which can lead to distorted thinking, often as automatic thoughts. This leads to emotional and behavioural reactions, which feed back into the core beliefs and confirm them. The reactions also lead to avoidance and withdrawal from situations where the core beliefs are triggered, so that new learning is less possible. This case formulation enables the client and practitioner to discuss the important processes that are going on and start a discussion about how these may be tackled. A treatment plan, treatment goals and a therapeutic contract emerge from the case formulation.
Interventions can address emotions, behaviour or thinking with interventions initially addressing any basic skills in these areas that need to be improved (Payne, 2014). Therapists choose interventions specific to the issues unearthed in the assessment. For example (Teater, 2013),
cognitive restructuring.
relaxation techniques.
social skills training.
assertion training and problem-solving skills.
systematic desensitization.
reinforcement, modelling and role-plays.
Harms (2007) suggests interventions often revolve around:
Challenging self-defeating or unhelpful beliefs through reframing.
Challenging helpful or unhelpful characteristics.
Including more information into the picture of understanding.
Hearing another point of view.
Controlling thoughts (thought stopping), e.g. wearing an elastic band around a wrist and flicking it when a negative thought is experienced.
Monitoring thoughts, e.g. through use of a journal.
Homework is often part of the implementation stage.
3. The evaluation stage serves as an opportunity to identify any changes that have occurred in the intensity, frequency and duration of thoughts, feelings and behaviours and the extent to which the presenting problem has diminished from pre- to post-intervention (Teater, 2013).
Tomlinson and Tomlinson (2011) outline in some detail the stages to use when implementing CBT with a family using the same three stages: assessment, intervention and evaluation. A summary of their article can be forwarded via email.
An Approach to Use with Positive CBT
The following approach for P-CBT is drawn from sources indicated.
1. Enhance the therapeutic alliance (Bannick, 2017; Prasko et al., 2016; Reichel, 2021; Sugay, 2021)
Build rapport (in the usual manner), but with a focus on uncovering strengths and solutions already present.
Allow talk about problems; listen and acknowledge but do not ask for details.
2. Do an assessment (first and foremost about strengths, resources, what works, and goals) (Bannick, 2017; Prasko et al., 2016; Reichel, 2021; Sugay, 2021)
After hearing about the problem, shift the focus from problem talk to strengths and solutions-based talk. For example, notice strategies a person employs to manage adversity (behavioural, cognitive, emotional, social, spiritual or physical).
Set goals to emphasise the possibility of change and begin to focus the person on future possibilities: ‘What will be the best outcome of you coming to see me?’ is a good way to start this part of the session, or ‘When can we stop meeting like this?’, or ‘What are your best hopes?’, followed by ‘What difference will it make when your best hopes are met?’
Collect all symptoms, complaints, and constraints and translate these into goals: ‘What would you like to see instead?’ ‘Suppose these problems would not be there, how will you or your life/relationship/work be different?’
3. Apply functional behavioural analysis to the problem (Bannick, 2017; Prasko et al., 2016; Reichel, 2021; Sugan, 2021)
Analyse the problem using A-B-C approach but examine desired behaviour and/or exceptions to the problem behaviour rather than analysing the problem behaviour itself. Three questions are used:
The ‘miracle’ question: Suppose tonight while you are sleeping, a miracle happens, and your problems are all solved. But because you are asleep, you don’t know that this miracle happens. What will be the first thing you notice tomorrow morning that will tell you that this miracle has happened? What will be the first thing you notice yourself doing differently that will let you know that this miracle occurred? What else? What else? What do you expect to see and find in the world around you, particularly your work?
Tell me about some recent times when you were doing somewhat better or (part of) the miracle was happening, even just a little bit.
When things are going somewhat better for you, what have you noticed that you or others do differently then? What other consequences have you noticed?
The therapist has a number of approaches to use with clients to help address how the client thinks and pays attention to the problem, how to change what the client is doing to solve the problem, and to help them focus on positive rather than negative emotions. These are outlined in detail in Bannick (2017) and Sugay (2021). A number of strategies are also used to build client strengths. These include shifting the attention and meaning, using the upward rather than the downward arrow technique, changing the behaviour, and changing the emotions. These are outlined in more detail in Prasko et al. (2016). These authors also examine the role of schemas in CBT and how to support a person to develop more adaptive schemas.
4. Invite the person to self-monitor strengths and exceptions to the problem (Bannick, 2017; Prasko et al., 2016; Reichel, 2021; Sugay, 2021)
This can occur in both the sessions and as homework: ‘What is better (since the last time we met)?’, ‘What is different (since the last time we met)?’, ‘What has been helpful (even just a little bit)?’
5. Homework tasks (Bannick, 2017; Prasko et al., 2016; Reichel, 2021; Sugan, 2021)
Homework is assigned between sessions. For example, the person can be asked to
Explore exceptions to the problem.
Gather evidence about when positive thoughts and beliefs are evident.
Act as if the preferred future has arrived.
6. Evaluation of the treatment (Bannick, 2017; Reichel, 2021)
At the end of every session clients are invited to give feedback about the relationship with the therapist, whether the goals and topics that they wanted to talk about were discussed, and whether the method or approach was a good fit for them—a session rating scale can be used (see Appendix 4).
Supporting Material/References
(available on request)
AACBT: Australian Association for Cognitive and Behaviour Therapy. (2015). What is CBT? Retrieved from https://www.aacbt.org.au/resources/what-is-cbt/
Bannink, F. (2107). Prosiive CBT in pratice. In C. Proctor (Ed.). Positive psychology interventions in practice (pp. 15-28). Springer International Publishing. Retrieved from https://www.fredrikebannink.com/bannink/wp-content/uploads/2017/04/PPIP_Positive-CBT-in-Practice.pdf
Blenkiron, P. (2022) Cognitive behavioural therapy (CBT). RC PSYCH: Royal College of Psychiatrists. Retrieved from https://www.rcpsych.ac.uk/mental-health/treatments-and-wellbeing/cognitive-behavioural-therapy-(cbt)
Connolly, M., & Healy, K. (2009). Social work practice theories and frameworks. In M. Connolly & L. Harms (Eds.). Social work: Contexts and practice (2nd ed., pp. 19-36). Oxford University Press.
Geschwind, N., Arntz, A., Bannin, F., & Peeters, F. (2019). Positive cognitive behavior therapy in the treatment of depression: A randomised order within-subject comparison with traditional cognitive behavior therapy. Behaviour Research and Therapy, 116, 119-130. https://doi.org/10.1016/j.brat.2019.03.005
Harms, L. (2007). Working with people: Communication skills for reflective practice. South Melbourne, Australia: Oxford University Press.
HEPMHCS: Hertfordshire Enhanced Primary Mental Health Care Services. (2010). Cognitive behavioural therapy skills training workbook: Learning more about low mood, stress, anxiety and how CBT can help you. Retrieved from http://www.socialworkerstoolbox.com/cognitive-behavioural-therapy-skills-training-workbook-learning-more-about-low-mood-stress-anxiety-and-how-cbt-can-help-you/
Leahy, R. L. (1997). Introduction: Fundamentals of cognitive therapy. In R. L. Leahy (Ed.). From practicing cognitive therapy: A guide to interventions (pp. 1-11). Jason Aronson Publishing. Retrieved from https://www.cognitivetherapynyc.com/wp-content/uploads/2021/02/arosnonintro.pdf
Leahy, R. L. (2009). What is cognitive therapy? Parts 1and 2. Retrieved from https://www.youtube.com/watch?v=gdFovvVJpr8 and https://www.youtube.com/watch?v=a4o2ujvXsmM
Morley, L. (2105). Cognitive behaviour therapy. Lecture at UNE in HSSW410.
Muroff, J. (2012). Cultural diversity and cognitive behaviour therapy. In L. Miller (Ed.), Counselling skills for social work (2nd ed., pp142-179). Sage. Retrieved from https://gacbe.ac.in/images/E%20books/Cognitive%20behavior%20therapy%20in%20clinical%20social%20work%20practice%20.pdf
Naeem, F. (2019). Cultural adaptations of CBT: A summary and discussion of the Special Issue on Cultural adaptation of CBT. The Cognitive Behaviour Therapist, 12(e40), 1-20. doi:10.1017/S1754470X19000278
National Health Service (UK). (n.d.). Every mind matters. https://www.nhs.uk/every-mind-matters/mental-wellbeing-tips/self-help-cbt-techniques/
NHS: National Health Service. (2019). Overview: Cognitive behavioural therapy (CBT). Retrieved from https://www.nhs.uk/mental-health/talking-therapies-medicine-treatments/talking-therapies-and-counselling/cognitive-behavioural-therapy-cbt/overview/
Payne, M. (2014). Modern social work theory (4th ed.). Red Globe Press.
Pease, B. (2009). From evidence-based practice to critical knowledge in post-positivist social work. In J. Allan, L. Briskman, & B. Pease (Eds.), Critical social work: Theories and practices for a socially just world. (2nd ed., pp. 45-57). Allen & Unwin.
Prasko, J., Hruby, R., Holubova, M., Latalova, K., Vuskocilova, J., Slepecky, M., Ociskova, M., & Grambal, A. (2016). Positive cognitive behavioural therapy. Activitas Nervosa Superior Rediviva, 58(1), 23-32.
Rathod, S., Phiri, P., & Naeem, F. (2019). An evidence-based framework to culturally adapt cognitive behaviour therapy. The Cognitive Behaviour Therapist, 12(e10), 1-15. doi:10.1017/S1754470X18000247
Reichel, A. (2021). Positive cognitive-behavioural psychotherapy. Psychoterapia, 1(196), 65-73. doi: 10.12740/PT/124981. Retrieved from http://psychoterapiaptp.pl/uploads/PT_1_2021/ENGver65Reichel_Psychoterapia_1_2021.pdf
Sugay, C. (2021). What is positive CBT? A look at positive cognitive-behavioural therapy. Retrieved from https://positivepsychology.com/positive-cbt/
Teater, B. (2013). Cognitive Behavioural Therapy (CBT). The Blackwell companion to social work, 423-427. Retrieved from https://www.researchgate.net/profile/Barbra-Teater-2/publication/264932879_Cognitive_Behavioural_Therapy/links/57656db908aeb4b998070cfa/Cognitive-Behavioural-Therapy.pdf
Thomlison, R. J., & Thomlison, B. (2011). Cognitive behaviour theory and social work treatment. In F. Turner (Ed.), Social work treatment: Interlocking theoretical approaches (5th ed.), (pp. 77-102). Oxford University Press.
Appendix 1
Sources of CBT
CBT is a combination of behavioural and cognitive therapies. Behavioural therapy seeks to modify learned behaviours that are problematic and undesirable and to replace them with more acceptable positive behaviours, particularly through the use of consequences and reinforcers. Cognitive therapy places an emphasis on the importance that people’s established beliefs or schemas play in the thought process which sustains problematic situations (Teater, 2013).
Payne (2014) provides the following diagrams, adding learning theory (classical and operant conditioning), social learning theory (copying the example of others), social skills training and mindfulness thinking to behavioural and cognitive therapies.
Respondent (classical) conditioning is the process of learning behaviour by connecting it to a stimulus. Many behaviours are unconditioned (dropping a hot object). But learned (conditioned) behaviours also occur and can become generalised. Unfortunately they do not always produce a good response and can develop into aberrant behaviour, e.g. social phobias.
Operant conditioning is based on the A-B-C model of behaviour, set out below. A situation (A) produces a behaviour (B) to deal with the situation. The behaviour results in consequences (C) that can strengthen (reinforce) or weaken the behaviour in future.
Appendix 2
Types of CBT
CBT is continually evolving. Here are some types of CBT have been shown to be effective; some have been used for many years while others are relatively recent (AACBT, 2015; Blenkiron, 2022):
Type of CBT | What do you do in this treatment | What can it help to treat? |
Cognitive therapy | Spot unhelpful thoughts and beliefs. Keep a record and try out more useful and realistic ways of thinking and reacting. | Many mental health problems (e.g. depression, anxiety) |
Behaviour therapy | Change unhelpful behaviours, like avoiding, checking or getting reassurance. Gradually face situations, thoughts or memories you've been avoiding. | Phobias, anxiety, OCD, PTSD |
Behavioural activation | Get more active and involved in life by doing things that give a sense of pleasure or achieveent. Keep a diary and schedule in positive activities. | Depression, low mood |
Problem solving therapy | Identify the problem, come up with ways of solving it, pick one solution and then put it into practice. | Practical difficulties (e.g. job, money) |
Motivational interviewing | Look at the pros and cons of a habit. Set goals for change. | Alcohol use |
Mindfulness | Pay attention to your thoughts and surroundings in the here and now without reacting to them | Recurrent depression, stress, anxiety |
Compassionate mind therapy | Be kinder and less cirtical of yourself and others, helping you to feel safer and more content. | Shape, anger, depression, low self-esteem, trauma |
Acceptance and commitment therapy (ACT) | Accept unpleasant thoughts and feelings rather than fight them or get upset. | Physical illness, pain, anxiety, depression |
Dialectical behaviour therapy (DBT) | Manage strong feelings and sudden mood changes to overcome relationship difficulties. Combines one-to-one CBT with group therapy. | Emotionally unstable or borderline personality disorder, repeat self-harm |
Cognitive analytic therapy | Understand past causes for current difficulties and find new ways of coping. Combines CBT with analytic therapy. | Anorexia nervosa, borderline personality disorder |
Schema therapy | Bring to light schemas suffered by a petient during childhood that have entrenched themselves in adult life. | Personality disorders, relapse after other therapies |
The approach “Positive CBT” has emerged in recent research and appears to be consistent with the strengths approach that is fundamental to social work.
Appendix 3
Online CBT
There are a number of online CBT resources available for people to access. The following is provided by AACB (2015)— https://www.aacbt.org.au/resources/online-resources/
E-HUB ONLINE MENTAL HEALTH PROGRAMS https://ehubhealth.com/
The e-hub research and development group is based at the Australian National University and provides free and anonymous online mental health services that are rigorously researched and based on the best available scientific evidence. They can be used as self-help programs or as adjuncts to other forms of therapy. All programs are anonymous, available 24/7 and free of charge.
BLUEPAGES bluepages.anu.edu.au
Comprehensive, evidence-based information about depression and its treatment (including medical, psychological and alternative therapies). BluePages also includes interactive depression and anxiety quizzes, descriptions of the experience and symptoms of depression, a relaxation download, and extensive resources for help.
MOODGYM moodgym.anu.edu.au
A popular interactive program which teaches cognitive-behaviour therapy skills for preventing and coping with depression. MoodGYM has been extensively researched and its effectiveness has been demonstrated in randomised controlled trials.
E-COUCH https://ecouch.com.au/home
e-hub’s latest interactive self-help program includes modules for social anxiety, generalised anxiety and depression. It provides skills training drawn from cognitive, behavioural and interpersonal therapies as well as relaxation and exercise.
BEACON beacon.anu.edu.au
Provides consumers and professionals with information about e-health online applications for mental health and physical health disorders. Websites throughout the world are reviewed and ranked by a panel of health experts. Consumers can also submit rankings and comments.
LIFE IN MIND (SUICIDE PREVENTION) https://lifeinmind.org.au/
Life in Mind is a national gateway connecting Australian suicide prevention services to each other and the community. Life in Mind links policy to practice, communities to help-seeking and practitioners to best practice, with the aim of better supporting the sector and the community to respond to and communicate about suicide and its impacts.
CENTRE FOR CLINICAL INTERVENTIONS (CCI) https://www.cci.health.wa.gov.au/
The Centre for Clinical Interventions (CCI) is a public mental health service in Western Australia. Their website has a range of free, evidence-based resources written by expert clinical psychologists to help consumers and healthcare professionals understand and manage mental health problems and related issues such as depression, bipolar, social anxiety, panic, self-esteem, procrastination, perfectionism, and eating disorders.
THIS WAY UP https://thiswayup.org.au/
THIS WAY UP is an Australian provider of evidence-based, internet-delivered Cognitive Behavioural Therapy (iCBT) programs for stress, anxiety, and depression. As a not-for-profit and joint initiative of St Vincent’s Hospital and the University of New South Wales, their stated mission is to reduce the burden of mental illness by providing accessible online treatment for anxiety disorders and related mental health conditions.
Appendix 4
Self-Help Techniques
National Health Service (UK). (n.d.). Every mind matters. https://www.nhs.uk/every-mind-matters/mental-wellbeing-tips/self-help-cbt-techniques/
Reframing unhelpful thoughts
The best way to deal with these unhelpful thoughts is to recognise them, challenge them, and see if you can replace them. For example, you might be worried about an important task you have to do at work, convinced it will go wrong and everyone will think you're a failure. Rather than immediately accepting this thought, and feeling even worse, take a moment to catch it and check it. Ask yourself whether there's good evidence for it, or if there are other explanations. Try thinking about what you would say to a friend who was thinking this way. Finally, see if you can change the thought for a more positive one. By catching the thought, checking it, and seeing if you can change it, with practise you can help break the negative cycle.
Tackling your worries
If worries are taking over your day, set aside a ‘worry time’ so you can shift your focus back to the here and now. When you sit down to think about your worries a structured technique called the ‘worry tree’ can help keep you focused on solutions rather than spiralling into negative thoughts.
First notice the worry, and then ask yourself, "What am I worried about?"
Try using the catch it, check it, change it technique to see whether you have considered all the angles.
Then, ask yourself if it's a worry you can do something about.
If it is, then write down a plan for it. What would you do? How could you do it? And when? If you identify immediate actions, do them now.
If the worry returns, remind yourself you have taken action on it and try and focus on something else.
If you can't do something about it now, schedule a time for when you can.
If the worry returns, remind yourself that you have a plan in place, and try and shift your attention to something else.
If you identify a worry that you can't do anything about, acknowledge this.
Worrying is part of life. We can't eliminate it completely.
But if anxiety is creeping in distract yourself with something else—exercise, yoga, breathing, mindfulness—to help calm down and return to the present.
Problem solving
Focus on your values—write down a few areas of your life that are most important to you right now – for example, a relationship, finances or a long-term goal like studying or developing your career. This can make it easier to prioritise which problems to tackle.
Tackle problems with possible solutions first. Some problems are hypothetical—things out of one’s control that can’t be dealt with by doing something practical. Make a list of problems that are solvable.
Set aside time to think through possible solutions to solvable problems. Write down pros and cons of each solution, whether it’s likely to work.
Choose a solution and make a specific plan (what to do, need support? time needed, when to do it)
Find a time to relax, e.g. get active, spend time on a hobby, muscle relaxation exercise.
Journaling may help—put it on paper.
Bouncing back from life’s challenges
Think about what you’re good at. What makes you good at it? What parts of your average day do you find easier?
Think about the difficulties you have overcome. What can you learn from this?
See how you can apply this elsewhere
When a challenge feels too difficult, change your thoughts to something more positive and see if that gives you energy to start on the challenge
If getting overwhelmed, take time to problem solve: what are the issues? what actions should I take first? What strategies have I used in the past? Can I look at the situation in a different way?
Reward achievements by doing something you really enjoy
Facing your fears
If instead we gradually expose ourselves to situations we fear, we can start to overcome them and feel more in control. This is sometimes called exposure therapy. Six steps can help.
When feeling relaxed, think about the way you feel physically when afraid.
Decide to gradually expose yourself to the activities you fear.
Rate the situations you fear from 0 to 100, with 100 causing most fear.
Start with the easiest by putting yourself in the situation until your fear has reduced by half.
Allow yourself to feel the fear to prove you can cope.
Work your way up the list.
Tacking your to-do list
Figure out your avoidance areas (areas you start and then stop). Are there common themes?
Plan you week with colours—routine jobs (cleaning), necessary tasks (paying bills), enjoyable activities (for fun). Have enough of each colour on your plan. See where to incorporate any avoidance areas.
Tackle avoidance areas.
For routine jobs use reminders, try it for 5 minutes, alternate between tasks you like and those that are difficult.
For necessary tasks, approach them when you feel most productive and energised and plan a reward for completion.
For enjoyable activities, make sure you schedule some of these each week.
Appendix 5
