Principles of CBT

Six principles of CBT guide treatment (Beck, 2005):

• A well-informed case formulation underpins successful intervention. The selection of CBT interventions is based on this conceptualization of the client and the client's problems in cognitive terms. Case formulation is an ongoing process; practitioners constantly integrate new information, which helps refine their clinical hypotheses and intervention approaches.
• A good working relationship between client and practitioner is required. The therapeutic alliance is one of the most important ingredients in successful treatment outcomes.
• Collaboration and participation are emphasized. The client is regarded as an expert on himself or herself and is assigned an active role in treatment. The end goal is to have the client become his or her own therapist.
• Concrete goals and problems are the target. Remain primarily present-oriented. However, the work of therapy can shift to examining the past when the client appears stuck and understanding how and when dysfunctional thoughts originated may help.
• Sessions are structured to allow the client and the practitioner to focus on what is most important and optimize the use of time.
• The client must learn to pick up on, examine and counter dysfunctional thoughts and beliefs. Using cognitive and behavioural interventions, the client gains insight into the meaning, validity and usefulness of thoughts and beliefs.

Techniques to challenge distorted thoughts and beliefs

• Role play—Rehearsing situations can heighten clients' awareness of automatic thoughts, help them develop a more balanced response and modify intermediate thoughts and beliefs (Beck, 2005). The effectiveness of role play is augmented by cognitive techniques such as coping statements.
• Behavioural experiments—Encourage clients to behave in a way that is inconsistent with their negative thought patterns. This can test the validity of unhelpful automatic thoughts, rules for living and core beliefs. Help clients design an experiment to test a balanced thought of which they are not convinced. Have them predict the outcome and anticipate problems and coping strategies. Then, have them rate the experiment's success and summarize what they learned. If the results do not support the balanced thought, clients should either design a different experiment or adjust their balanced thoughts.
• Coping cards—Reminder notes help clients reference balanced thoughts when required. Write balanced thoughts on sticky notes or cue cards that can be carried or stuck on a surface for easy access. Encourage clients to read their coping cards daily and as needed (Beck, 2005).
• Referral—For many clients, learning to modify automatic thoughts and maladaptive responses is enough to help them cope. Other clients may need deeper changes. Getting to the root of the problem may require restructuring intermediate and core beliefs. Although the same interventions can be used, it can be trickier to identify and verbalize more fundamental thoughts. The process can be challenging and may require more sessions than resources in a primary care setting allow. At this point, referral should be considered.