Demystifying CBT: Effective, easy-to-use treatment for depression and anxiety

Restructuring negative beliefs

A variety of techniques can be used to restructure negative beliefs.

• Cost-benefit analysis involves exploring advantages and disadvantages of maintaining a negative belief or a more-balanced alternate belief.
  
• Core belief logs¹² can track day-to-day evidence that suggests a core belief is not 100% true. You and the patient can scrutinize evidence that supports the core belief and reframe the evidence in a more-rational manner.
  
• Life review^10,12 involves asking the patient to re-evaluate a core belief ’s historical underpinnings and to reframe these events from an adult perspective.
  

Automatic thoughts might be restructured quickly, but core beliefs may take months to begin to change. Techniques focused on rational reappraisal are usually not sufficient by themselves. Supplemental approaches that focus on activating and amplifying emotion can be integral to this process. Examples include:

• rational-emotional role play
  
• empty chair or two-chair dialogue
  
• restructuring early memories with directed imagery.
  

Adjunctive Behavioral Strategies

Behavioral interventions are used in CBT to combat anergia, increase socialization, diminish avoidance, and accumulate data to challenge negative beliefs. Common strategies are designed to enhance self-esteem and confidence and build therapeutic momentum as patients gain energy, feel better, and disconfirm negative beliefs.

Activity monitoring and scheduling. Instruct anergic or avoidant patients to monitor daily activities for the week and to rate the degree of pleasure and accomplishment each activity yields on a scale of 1 to 10. As patients become aware of how much time they spend on low-yield activities, help them gradually replace low-yield with higher-yield activities.

Schedule into the week behavioral goals patients identified at the beginning of therapy. Schedule avoided tasks such as household chores, and link them to pleasurable activities as rewards. To evaluate the accuracy of their thinking, ask patients to predict how much pleasure or mastery they will achieve with scheduled activities, then compare their predictions with actual results.

Also ask patients to anticipate obstacles to achieving their goals, to challenge those obstacles, and to develop contingency plans. Reviewing the patient’s week and its bright spots can disconfirm negatively biased recall such as, “My week was terrible,” or, “I don’t have the energy to do anything anymore.”¹³

Graded task assignments. When scheduling activities, improve success rates by helping patients break down large, unrealistic goals into smaller, more manageable pieces. Ask them to consider realistically what they can accomplish now, not what they could have accomplished before they became ill.

Exposure. Anxious patients avoid feared situations because of catastrophic beliefs that experiencing those situations will harm them. A man with panic disorder may avoid exercise, for example, because he perceives lightheadedness and rapid heart rate as signs of imminent heart attack. Avoiding exercise to prevent the feared symptoms perpetuates his catastrophic beliefs.

Exposure to feared symptoms—while initially arousing high anxiety—allows the patient to experientially disconfirm his beliefs. As he remains well after lightheadedness and rapid heart rate are induced interoceptively (by climbing several flights of stairs, for example), he comes to recognize the situational symptoms as manifestations of anxiety rather than evidence of life-threatening illness.^2,3

In vivo exposure entails confronting the patient with the avoided object or situation. For example, you may show a woman with needle phobia pictures of needles, followed by actual needles themselves, then ask her to touch a needle, hold a needle, etc., until her anxiety gradually diminishes.

Imaginal exposure involves asking the patient to imagine himself in a feared situation and manipulating the images to build his sense of mastery. If he stops the image at the moment of highest arousal, instruct him to “continue to play the film forward” by asking, “What happens next?” This approach shows him that he can cope with difficult situations.

Related resources

For clinicians

• Persons JB. Cognitive therapy in practice: a case formulation approach. New York: WW Norton and Co.; 1989.
  
• Academy of Cognitive Therapy. Training, certification as a cognitive therapist. www.academyofct.org.
  
• Behavior Online. Gathering site for mental health professionals. www.behavior.net.
  
• MySelfHelp.com. Interactive programs and moderated discussion designed as treatment adjuncts for patients with depression, stress, eating disorders, etc. Funded by the National Institute of Mental Health ($20/month program access fee). www.MySelfHelp.com.
  

For patients

• Antony M, Swinson R. When perfect isn’t good enough. Oakland, CA: New Harbinger Press; 1998.
  
• Antony M, Swinson R. The shyness and social anxiety workbook. Oakland, CA: New Harbinger Press; 2000.
  
• Young J, Klosko J. Reinventing your life: how to break free from negative life patterns. New York: Dutton; 1993.
  
• Davis M, Eshelman E, McKay M. The relaxation and stress reduction workbook. New York: New Harbinger Press; 1995.