Silvina Galperin, D. Psych., C. Psych
For Internationally trained
Cognitive therapy is an active, directed,
time-limited, structured approach, used
to treat a variety of psychiatric disorders
(depression, anxiety, phobias, chronic
pain and others)
It is based on an underlying theoretical
rationale that an individual’s affect and
behaviour are largely determined by the
way in which he structures the word
Aaron Beck (1979)
n Present oriented
n Based on an ongoing case
n Educative: teaches patient to be self-
n Goal oriented: problem focused
n Variety of techniques to change thoughts,
feelings and behaviour
n Relapse prevention
Principles of Cognitive Therapy
n Strong therapeutic alliance
n Goal oriented and problem focused
n Emphasizes skill acquisition
n Uses cognitive and behavioural techniques to
change thinking, mood and behaviour.
n Thought records, Socratic questioning, action
plans, behavioral experiments, cognitive
continuum, exposure and other techniques to
evaluate and modify dysfunctional thoughts
and beliefs (cognitive restructuring).
Suitability for Brief Cognitive
n Accessibility of Automatic Thoughts
n Awareness and differentiation of emotions
n Acceptance of personal responsibility with
n Compatibility with cognitive rationale
n Alliance potential (in-session)
n Alliance potential (out- of-session)
n Security operations
n Chronicity vs. Acuteness
n Optimism vs. Pessimism
Safran, J., Segal, Z. (1990) Interpersonal process in
Cognitive Therapy. Basic Books. New York
Structure of the CBT Session
1. Mood check up
n How was your mood during the past week?
n What did you work on during the last week?
2. Bridge from previous session
n What did you learn in the last session?
n Was there anything that bothered you our last session?
3. Agenda Setting
n What problems do you want to put on the agenda?
n Which ones have priority for today’s session?
4. Review of Homework
5. Discussion of the Agenda, new
6. Final summary and feedback
n What do you think about today’s session?
n What will be important for you to remember?
The Cognitive Model
nThe cognitive model states that the
behaviour is reciprocally
determined by the individual’s
thoughts, feelings and physiological
nNone of these elements is
necessarily more important.
nThe therapist can intervene by
focusing on each of these areas at
different times of the treatment.
How to use the Cognitive Model
with the clients: Examples
n 1. Pierre is a VP of multinational company. Three months ago
he was diagnosed with rosacea. He thinks that to have his face
red is a sign of weakness and that people will think he is afraid
or nervous and this makes him feel extremely uncomfortable,
irritable and anxious.
n 2. Chris is a 21 year old student that is afraid of meeting people.
He has friends but when there are new people around he just
n 3. Greta is a 67 year old married, retired woman who has been
avoiding to get out of her home for 2 months. She had several
episodes of diarrhea at home and now she is afraid of having
an “accident” anytime.
n Typical cases of depression
n Typical cases of separation anxiety
Introducing the Cognitive Model
to a client
-Groups of Three-
1. Patient: Describes situation, answers therapist’s questions
2. Therapist: Asks questions to the client to clarify
3. Observer: Assists therapist and/or client, gives feedback
1. Ask about a specific situation (where, when, with who, what
happened) in which the change of mood occurred (started to feel
afraid, embarrassed, anxious, etc.)
2. Ask about all the emotions that this situation triggered in the client
and write it down
3. What was going through your mind just before you started to feel
this way? What other thoughts did you have at that moment?
4. Ask about specific physical sensations associated
5. What was the resulting behaviour at that time
n Why set goals for therapy?: CBT is a time-limited.
Setting some specific goals ensures that we work with a
focus and clients get the most out of therapy. It also
allows to track the progress in therapy.
Goals are based on the client’s expectations for
n What would you like to accomplish in therapy?
n What woul ou like to be different in your life?
Overall areas that need improvement
n I want to be healthier
n I want to take better care of myself
n I want to have friends
Observable and reasonable changes that can be
n What can do to start?
n List small steps towards the goal
n Are the steps observable?
Questions to answer:
n Where are you now?
n Where you would like to get?
n What small steps can you take to
get from where you are now to
where you want to be?
Practice setting up goals
n Define general goals
n Prioritize 3 (the ones that would give most
For each goal :
n Where are you now?
n Where would you like to be?
n Define small, reasonable, achievable,
measurable steps to take.
n Rate level of difficulty of each step
n Arrange according to the level of difficulty
starting from the easiest.
n Ask: What would be the first sign that you are
n Practice setting up 8 small steps towards a
n Are thoughts that pop into our heads
automatically throughout the day
n We don’t have the intention of having
n Usually, we are not even aware of them
n One of the goals of cognitive therapy is
to bring automatic thoughts into
n I.E.: If you are late for an appointment,
what would you think as you are
traveling to get there?
What was going through your mind when you had that
strong feeling (or reaction to something)?
1. Ask this question when you notice a shift in affect during
2. Have the client describe a problematic situation or a time
during which he/she experienced a shift in affect
3. If needed, use imagery to describe the situation in detail
"as if it's happening now«
4. If needed have the client roleplay a specific interaction
Other questions to elicit automatic thoughts:
1. What do you guess you were thinking about?
2. What did this situation mean to you?
3. What images or memories did you have in this situation?
4. What were you afraid might happen?
5. Were you thinking____________? (Therapist supplies an
automatic thought opposite to the expected one.)
6. What does this say about you, your life, your future?
What are the cognitions we
evaluate in therapy?
Perceptions Attributions of
cause as to
n Is the thought that is more emotionally
charged -- strongly connected with the
n Is the thought that triggers the mood
n Appear spontaneously during the day.
n It can be words, images or memories.
n We circle the Hot Thought in the
Thought Record and focus on this
First 3 columns
Situation Mood Automatic
(Rate 0-100%) Thoughts
1. What (Circle Hot Thought)
4. With who
Evidence that supports
the Hot Thought
n We ask for facts, things that actually happened
in the past.
n This includes situations, experiences, reactions,
n We don’t write down ideas, interpretations of
facts or thoughts in this column
Evidence Against the
n Have I had any experiences that don’t support the H.T.
or that would indicate that it is not 100% true?
n If my best friend would have this thought, what would I
n When I am not feeling this way, do I think differently in
the same situations? How?
n When I felt this way in the past, what helped me feel
n In five years from now, would I look at this situation
differently? Would I focus on a different part of my
n Are there any positives in me or the situation that I am
n Am I blaming myself for something over which I do not
have complete control?
Adaptation from Mind over Mood, Greenberger, Padesky 1995 Guildford Press
How to create a Balanced or
n Considering the information listed for and against the
hot thought, is there an alternative way of understanding
or thinking about this situation?
n Write one sentence summarizing or combining the
information of both columns (using “even though”,
n Can other people think of other way of understanding
n If a friend of mine would be in this situation, how would
I suggest to understand it?
n If my hot thought is true, what is the worst, the best and
the most realistic outcome?
Adaptation from Mind over Mood, Greenberger, Padesky 1995 Guildford Press
n Are patterns of dysfunctional thinking
n Instead of reacting to the reality of an
event, an individual reacts with a
personal interpretation that is partial.
n For example, a person may conclude
that is worthless just because he was not
invited to a party or did not pass an
n Cognitive therapists make patients aware
of these distorted thinking patterns.
-Patterns of negative thinking-
1. All or nothing thinking: You view a situation in only two
categories instead of on a continuum.
"If I'm not a total success, I'm a failure."
2. Castastrophizing: You predict the future negatively without
considering other, more likely outcomes.
" I’ll be so upset, I won't be able to function at all."
3. Disqualifying or discounting the positive: You
unreasonably tell yourself that positive experiences or qualities do
not count. I did that project well, but that doesn't mean I'm competent; I
just got lucky."
4. Emotional reasoning: You think something must be true because
you "feel" (actually believe) it so strongly, ignoring or discounting
evidence to the contrary.
"I know I do a lot of things okay at work, but I still feel like a failure.»
5. Labeling: You put a fixed, global label on yourself or others
without considering that the evidence might more reasonably lead
to a less disastrous conclusion.
"I'm a loser." " He's no good. »
6. Magnification/minimization: When you evaluate yourself,
another person, or a situation, you unreasonably magnify the
negative and/or minimize the positive.
"Getting a mediocre evaluation proves how inadequate I am. Getting high
marks doesn't mean I'm smart."
3 columns exercise to identify cognitive
Automatic Identify Alternative
Thought Cognitive Thought
If I don’t present Mental Filter Even if this report
an excellent report Catastrophizing is not presented in
to my boss, he an excellent way, I
might fire me and am an efficient,
I won’t have reliable and
money to support experienced
my family. employee and
(Anxious 90% would not be so
Afraid 80% ) easy to replace me.
Examples of Non-Socratic
(note how much less useful they are. )
1. Why are you being so hard on yourself?
2. What's the big deal about yelling at
your kids? Almost everyone does it.
3. Didn't your parents ever yell at you?
4. I'm sure your kids will get over it. It doesn't
seem so bad to me .
5. You're basically a great mother; don't you
remember what you told me you did for your
kids the other day?
Read more about Cognitive
Behavioural Therapy here: