Developing The Therapeutic

Relationship
 It is essential to start building trust and rapport with
patients from your first contact with them. Research
demonstrates that positive alliances are correlated
with positive treatment outcomes (Raue & Goldfried,
1994).
 You will continuously demonstrate your commitment
to and understanding of patients through your
empathic statements, choice of words, tone of voice,
facial expressions, and body language
 “I care about you and value you.”
 “I want to understand what you are experiencing
and help you.”
 “I’m confident we can work well together and that
cognitive behavior therapy will help.”
 “I’m not overwhelmed by your problems, even
though you might be.”
 “I’ve helped other patients much like you.”
Sharing Your Conceptualization and
Treatment Plan
 You will continuously share your conceptualization with patients and ask them
whether it “rings true.” For example, a patient may have just described a problem
with her mother. You have questioned her to fill in the cognitive model.
 Then you conceptualize aloud, in summary form.
 “Okay, I want to make sure I understand. The situation was that your mother yelled
at you on the phone for not calling your brother, and your automatic thought was,
‘She doesn’t realize how busy I am. She doesn’t blame him for not calling me.’
 These thoughts led you to feel hurt and angry, but you didn’t say anything back to
her [behavior]. . . . Did I get that right?” If your conceptualization is accurate, the
patient invariably says, “Yes, I think that’s right.” If you are wrong, the patient
usually says, “No, it’s not exactly like that. It’s more like . . .”
 Eliciting patients’ feedback strengthens the alliance and allows you to more
accurately conceptualize them and conduct effective treatment.
 Making Collaborative Decisions

 You will help them prioritize the problems they

want help in solving during a session. You will
provide rationales for interventions and elicit their
approval (“I think it may reduce your stress if you
take a rest a couple of times a day—is it okay if
we talk about that?”).
 Seeking Feedback
 You will be continuously alert for your patients’ emotional reactions throughout the
session, observing their facial expressions, body language, choice of words, and
tone of voice.
 When you recognize that patients are experiencing increased distress, you will
often address the issue at the time: “You look upset.
 What was just going through your mind?” You may find that patients express
negative thoughts about themselves, the process of therapy, or you.
 Even when you discern that your alliance with patients is strong, you will still elicit
feedback from them at the end of sessions:
 “What did you think about the session? Was there anything that bothered you, or
you thought I misunderstood? Is there anything you want to do differently next
time?” Asking these questions can strengthen the alliance significantly.
 Helping Patients Alleviate Their
Distress
 In general, you will spend enough time developing the therapeutic
relationship to engage patients in working effectively with you as a team,
and you will use the therapeutic alliance to provide evidence to patients
that their core beliefs are incorrect.
 If the alliance is sound, you will avoid spending additional unnecessary
time to maximize the time you spend helping patients solve problems they
will face in the coming week.
 Some patients, particularly those with personality disorders, do require a
far greater emphasis on the therapeutic relationship and advanced
strategies to forge a good working alliance (Beck, Freeman, Davis, &
Associates, 2004; J. S. Beck, 2005; Young, 1999).
 Guided Discovery
 Usually in the context of discussing a problem, you elicit patients’ cognitions
(automatic thoughts, images, and/or beliefs).
 You will often ascertain which cognition or cognitions are most upsetting to
patients, then ask them a series of questions to help them gain distance (i.e., see
their cognitions as ideas, not necessarily as truths), evaluate the validity and utility
of their cognitions, and/or de-castastrophize their fears.
 Questions such as the following are often helpful:
 Behavioral Experiments
 Whenever possible, you will collaboratively design experiments that patients can
conduct right in the therapy session itself (as well as between sessions).
 Discussing the validity of patients’ ideas, as described above, can help them change
their thinking, but the change may be significantly more profound if the cognition
is amenable to a behavioral test, that is, if the patient can have an experience that
disconfirms its validity (Bennett-Levy et al., 2004).
 Suitable cognitions are usually linked to patients’ negative predictions. A depressed
patient, for example, might have the automatic thought, “If I try to read anything, I
won’t be able to concentrate well enough to understand it.”
 Emphasizing the Positive

 At the evaluation, you will elicit patients’

strengths (“What are some of your strengths
and positive qualities?”). From the first
session on, you will elicit positive data from
the preceding week (“What positive things
happened since I saw you last? What
positive things did you do?”).
 You will orient sessions toward the positive,
helping patients have a better week.
 You will point out the positive data you hear as
patients discuss problems and ask what this data
means about them (“What does this say about
you, that you got the job in the bookstore?”).
 You will be on alert for, and note aloud, instances
of positive coping that patients may mention to
throughout the session (“What a good idea, to
solve the problem by asking Allison to study with
you”).
 Identifying automatic thoughts and beliefs when
patients notice a dysfunctional change in affect,
behavior, or physiology, and then evaluating and
responding to their cognitions through Socratic
questioning, behavioral experiments, and/or
reading therapy notes that address their
cognitions. For example:
 Cognitive Conceptualization

 A cognitive conceptualization provides the

framework for understanding a patient. To initiate
the process of formulating a case, you will ask
yourself the following questions:
 Then you will hypothesize how the patient
developed this psychological disorder:
 The Cognitive Model

 Cognitive behavior therapy is based on the

cognitive model, which hypothesizes that people’s
emotions, behaviors, and physiology are
influenced by their perception of events.
 The way people feel emotionally and the way they behave are
associated with how they interpret and think about a situation.
 The situation itself does not directly determine how they feel
or what they do; their emotional response is mediated by their
perception of the situation.
 Cognitive behavior therapists are particularly interested in the
level of thinking that may operate simultaneously with a more
obvious, surface level of thinking.
 For example, while you are reading this text, you may notice two levels in
your thinking.
 Part of your mind is focusing on the information in the text; that is, you are
trying to understand and integrate the information.
 At another level, however, you may be having some quick, evaluative
thoughts. These thoughts are called automatic thoughts and are not the
result of deliberation or reasoning.
 Rather, these thoughts seem to spring up spontaneously; they are often
quite rapid and brief.
 You may barely be aware of these thoughts; you are far more likely to be
aware of the emotion or behavior that follows.
 Beliefs
 Beginning in childhood, people develop certain ideas about themselves, other people, and
their world.
 Their most central or core beliefs are enduring understandings so fundamental and deep that
they often do not articulate them, even to themselves.
 The person regards these ideas as absolute truths—just the way things “are” (Beck, 1987).
 For example, Reader E, who thought he was too unintelligent to master this text, frequently
has a similar concern when he has to engage in a new task (e.g., learning a new skill on the
computer, figuring out how to put together a bookcase, or applying for a bank loan). He seems
to have the core belief, “I’m incompetent.”
 This belief may operate only when he is in a depressed state, or it may be activated much of
the time. When this core belief is activated, Reader E interprets situations through the lens of
this belief, even though the interpretation may, on a rational basis, be patently invalid.
 Reader E tends to focus selectively on information that confirms his core
belief, disregarding or discounting information to the contrary. For
example, Reader E did not consider that other intelligent, competent people
might not fully understand the material in their first reading.
 Nor did he entertain the possibility that the author had not presented the
material well.
 He did not recognize that his difficulty in comprehension could be due to a
lack of concentration, rather than a lack of brainpower.
 He forgot that he often had difficulty initially when presented with a body
of new information, but later had a good track record of mastery.
 Because his incompetence belief was activated, he automatically
interpreted the situation in a highly negative, self-critical way.
 In this way, his belief is maintained, even though it is inaccurate and
dysfunctional. It is important to note that he is not purposely trying to
process information in this way; it occurs automatically.
 Strengthen the negative core belief.
 There are also positive data that Reader E just does not notice.
 He does not negate some evidence of competence, such as
paying his bills on time or fixing a plumbing problem. Rather,
he does not seem to process these positive data at all; they
bounce off the schema. Over time, Reader E’s core belief of
incompetence becomes stronger and stronger.
 Sally, too, has a core belief of incompetence. Fortunately,
when she is not depressed a different schema (which contains
the core belief, “I’m reasonably competent”) is activated
much, but not all, of the time. But when she is depressed, the
incompetence schema predominates.
 One important part of therapy is to help Sally view negative
data in a more realistic and adaptive way. Another important
part of therapy is to help her identify and process positive data
in a straightforward way.
 Core beliefs are the most fundamental level of belief;
they are global, rigid, and overgeneralized.
 Automatic thoughts, the actual words or images that
go through a person’s mind, are situation specific and
may be considered the most superficial level of
cognition.
Attitudes, Rules, and Assumptions
 Core beliefs influence the development of an intermediate class of beliefs, which consists of
(often unarticulated) attitudes, rules, and assumptions. Reader E, for example, had the
following intermediate beliefs:
 Attitude: “It’s terrible to fail.”
 Rule: “Give up if a challenge seems too great.”
 Assumptions: “If I try to do something difficult, I’ll fail. If I avoid
 doing it, I’ll be okay.”
 These beliefs influence his view of a situation, which in turn influences how he thinks, feels,
and behaves. The relationship of these intermediate beliefs to core beliefs and automatic
thoughts is depicted below:
 The quickest way to help patients feel better and behave more adaptively is
to facilitate the direct modification of their core beliefs as soon as possible,
because once they do so, patients will tend to interpret future situations or
problems in a more constructive way.
 It is possible to undertake belief modification earlier in treatment with
patients who have straightforward depression and who held reasonable and
adaptive beliefs about themselves before the onset of their disorder.
 Therapists teach patients to identify
 These cognitions that are closest to conscious awareness, and to gain
distance from them by learning:
 Just because they believe something doesn’t
 Necessarily mean it is true.
 Changing their thinking so it is more reality based and useful helps them
feel better and progress toward their goals.
 It is easier for patients to recognize the distortion in their specific thoughts
than in their broad understandings of themselves, their worlds, and others.
But through repeated experiences in which they gain relief by working at a
more superficial level of cognition, patients become more open to
evaluating the beliefs that underlie their dysfunctional thinking.
 It is important to note that the sequence of
the perception of situations leading to
automatic thoughts that then influence
people’s reactions is an oversimplification at
times.
 Thinking, mood, behavior, physiology, and
the environment all can affect one another.
Triggering situations can be:
It is important to put yourself in your patients’ shoes,
to develop empathy for what they are undergoing, to
understand how they are feeling, and to perceive the
world through their eyes.
 Conceptualization begins at the first contact with patients and is refined at
every subsequent contact. You make hypotheses about patients, based not
just on the cognitive formulation of the case, but also on the specific data
patients present.
 You confirm, disconfirm, or modify your hypotheses as patients present
new data. The conceptualization, therefore, is fluid. At strategic points, you
will directly check your hypotheses and formulation with patients.
 Generally, if the conceptualization is on target, patients confirm that it
“feels right”—they agree that the picture the therapist presents truly
resonates with them.
 Sally’s Core Beliefs
 As a child, Sally tried to make sense of herself, others, and her world.
 She learned through her own experiences, through interactions with others, through
direct observation, and through others’ explicit and implicit messages to her.
 Her perceptions were also undoubtedly influenced by her genetic inheritance. Sally
had a highly achieving older brother.
 As a young child, she perceived that she could not do anything as well as her
brother and started to believe, although she did not put it into words, that she was
incompetent and inferior. She kept comparing her performance to that of her
brother and invariably came up lacking.
 She frequently had thoughts such as: “I can’t draw like Robert can.”
 Not all children with older siblings develop these
kinds of dysfunctional beliefs.
 But Sally’s ideas were reinforced by her mother,
who frequently criticized her: “You did a terrible
job straightening up your room. Can’t you do
anything right?”
 At school, Sally also compared herself to her
peers. While she was an above-average student,
she compared herself only to the best students,
again coming up short.
 She had thoughts such as: “I’m not as good as
they are.” “I’ll never be able to understand all this
as well as they can.” So the idea that she was
incompetent and inferior was reinforced.
 Sally’s core beliefs about her world and about
other people were, for the most part, positive
and functional.
 She generally believed that other people
were well-intentioned, and she perceived her
world as being relatively safe, stable, and
predictable.
 Sally’s Attitudes, Rules, and
Assumptions
 Somewhat more amenable to modification than her core
beliefs were Sally’s intermediate beliefs.
 These attitudes, rules, and assumptions developed in the same
way as core beliefs, as Sally tried to make sense of her world,
of others, and of herself.
 Mostly through interactions with her family and significant
others, she developed the following attitudes and rules:
 As was the case with her core beliefs, Sally had not fully articulated these
intermediate beliefs.
 But the beliefs nevertheless influenced her thinking and guided her
behavior. In high school, for example, she did not try out for the school
newspaper (although it interested her) because she assumed she could not
write well enough.
 She felt both anxious before exams, thinking that she might not do well,
and guilty, thinking that she should have studied more.
 Sally’s Coping Strategies

 The idea of being incompetent had always been

quite painful to Sally, and she developed certain
behavioral strategies to cope or compensate for
what she saw as her shortcomings.
 As might be gleaned from her intermediate
beliefs, Sally worked hard at school and at sports.
She over-prepared her assignments and studied
quite hard for tests. She also became vigilant for
signs of inadequacy and redoubled her efforts if
she
 Sequence Leading to Sally’s
Depression
 Sally may have had a genetic predisposition
toward developing depressogenic beliefs. Not
all negative events, however, led her to feel
dysphoric.
 She was able to get along until her innate
vulnerability, influenced by the presence of
negative beliefs, was challenged by a series
of matching stressors (the “diathesis– stress”
model; Beck, 1967).
 When Sally began college, she had several experiences that she interpreted
in a highly negative fashion.
 One such experience occurred the first week. She had a conversation with
other freshmen in her dorm who were relating the number of advanced
placement courses and exams they had taken that had exempted them from
several basic freshman courses.
 Sally, who had no advanced placement credits, began to think how superior
these students were to her. In her economics class, her professor outlined
the course requirements and Sally immediately thought, “I won’t be able to
do the research paper.” She had difficulty understanding the first chapter in
her chemistry text and she thought, “If I can’t even understand Chapter 1,
how will I ever make it through the course?”
 She withdrew somewhat from new friends at school and
stopped calling her old friends for support.
 She discontinued running and swimming and other activities
that had previously provided her with a sense of
accomplishment.
 Thus she experienced a paucity of positive inputs. Eventually,
her appetite decreased, her sleep became disturbed, and she
became enervated and listless.
 Sally’s perception of and behavior in the circumstances at the
time facilitated the expression of a biological and
psychological vulnerability to depression.
 Conceptualizing a patient in cognitive terms is
crucial to determining the most efficient and
effective course of treatment.
 It also aids in developing empathy, an ingredient
that is critical in establishing a good working
relationship with the patient.
 In general, the questions to ask when
conceptualizing patients are: