Cognitive Behaviour Therapy, 2 ed.

Chapter 1. Understanding CBT for Goal Achievement

‘People are not disturbed by events but by the view they hold about them.’

Epictetus, Stoic philosopher c. AD 75

This chapter will introduce you to some of the basic ideas and principles of Cognitive Behaviour Therapy (CBT) and how you can use it to help you achieve your goals. First though, what does Cognitive Behaviour Therapy (CBT) actually mean?

Cognitive simply means our ‘thinking processes’: how we think, how we acquire information and knowledge, how we store it in our head, how we evaluate it and how we base some of our decisions on it.

Behaviour means our action or reaction to something. It's the doing bit. Our behaviour can be conscious or unconscious (out of our conscious awareness). In CBT, the word ‘behaviour’ comes from a branch of psychology called ‘behaviourism’, which is concerned with what can be observed rather than what can be speculated or assumed. It is based on what you have learned and become accustomed to, how this affects your actions and feelings, and how you can unlearn what you have learned in order to change.

Therapy means the treatment for a health problem after a diagnosis or an assessment has been made.

CBT is a form of therapy that examines how our thinking, attitudes, beliefs, opinions and behaviour are formed, how they affect our success, our lives and feelings, and how changing them impacts on our performance. The ideas stem from both ancient and modern thinking in philosophy, science, psychology, common sense and humanity.

Here are some of basic principles central to CBT. Many may be shared by other therapeutic approaches, but the combination of these principles goes some way towards understanding CBT.

The Emotional Responsibility Principle

‘People are not disturbed by events but by the view they hold about them.’

This principle is at the heart of nearly all emotional and behavioural change. It can be challenging because you may believe that it's what has happened to you that ‘makes’ you feel how you feel and do what you do in the here and now.

I hope that by questioning this you will learn that what you believe may be stopping you from empowering yourself to move forward with your life. This in turn may help you in the pursuit of your desired goals.

Is it true that events, situations or people make us feel what we feel?

First, let's look at the popular notion that your feelings are ‘caused’ by events, situations or other people.

Think of a past event that you think ‘made’ you feel and do something. By this logic the only way you can change your feelings now is to wish the event had not happened in the first place.

Maybe you think there's someone else who has ‘made’ you feel and act in a certain manner. In which case, the only way you can change your feelings now is to get that person from the past to undo what they did or said. And if that person is now deceased, how can this be done?

Believing that the past, or a particular situation or person, causes our feelings today, means that no one would ever be able to move forward or to change. We would all be totally stuck without any possibility or hope of ever changing anything. We would be slaves to the things that had happened to us or the people we had been involved with.

Can you imagine what it would be like if everyone felt hurt every time they experienced a rejection of some sort?

Rejection = Hurt

10 people rejected = 10 people feeling hurt

100 people rejected = 100 people feeling hurt

1000 people rejected = 1000 people feeling hurt

As an example, when you experience rejection you might feel hurt. However, if you believe that your feelings are caused by others, you may then believe that being rejected by someone is the cause of your hurt feelings. But don't some of us experience different emotions if rejected by someone we like? Maybe anger, sadness, depression or relief?

In fact, different people may feel different emotions when they experience the same event:

1. Some people feel hurt

2. Some people feel angry

3. Some people feel depressed

4. Some people couldn't care less

Why do different people feel different things and what is at the heart of their feelings?

Is it true that events or people make us do what we do?

Let's think about what we do and assume that situations or people make us behave as we do.

A colleague criticizes you = You start avoiding them

If it is true that a colleague's criticism ‘made’ you avoid them, this means that every criticism made by your colleague would have the same effect on everyone. It means that avoidance is the only possibility whenever your colleague criticizes you, or anyone else for that matter.

A colleague criticizes 10 people = 10 people avoid them

A colleague criticizes 100 people = 100 people avoid them

A colleague criticizes 1000 people = 1000 people avoid them

Does this make sense?

The problem is that people say, ‘he made me do it’ or ‘she made me lose my temper’. It is as if they have absolutely no control over their behaviour. Once again, if we do not have a part to play in how we behave then we would be completely stuck, unable to move forward, learn or do anything useful. Is this what you see happening to everyone around you?

So what provokes your feelings and behaviour? Most of the time the simple answer is that you do. You provoke your feelings and actions by the way you think, the attitudes you've formed, the habits you no longer question and the beliefs you hold.

This is the principle of emotional responsibility: you are largely responsible for the way you feel and act.

The principle of emotional responsibility can be challenging, particularly if you are going through a difficult time or have experienced trauma or personal tragedy. It's natural to feel angry, sad, depressed or hurt in response to accidents, illness and other challenges in life, but if you get stuck in these feelings then you can change them.

The thought manifests as the word; The word manifests as the deed; The deed develops into habit;

And habit hardens into character;

So watch the thought and its ways with care. (Buddha)

The way you think about something affects how you feel and how you behave. Here are some examples:

· If you think that your partner's late arrival for dinner proves that you are not lovable then you might feel hurt and sulk.

· If you think that your partner was nasty and selfish because they arrived late for dinner then you might feel angry and shout.

· If you think that your partner's late arrival for dinner is no big deal then you can feel calm about it and ask what happened.

This shows that it is not the situation or what happens to us that provokes our feelings and behaviour. It is the way we think about the situation. The way we think about something can then influence how we behave.

The Behavioural Principle

CBT considers behaviour as significant in maintaining or in changing psychological states. If, for example, you avoid some event, such as giving a presentation to your team, then you will deny yourself the opportunity to disconfirm your negative thoughts about yourself or capabilities. Furthermore, avoidance only sabotages what you want to achieve. Changing what you do is often a powerful way of helping you change thoughts and emotions and ultimately what you can achieve.

The ‘Here and Now’ Principle

Traditional therapies take the view that looking at problems in the here and now is superficial. They consider successful treatment must uncover the childhood developmental issues, hidden motivations and unconscious conflicts that are supposed to lie at the root of the problem. These approaches argue that treating the current problem rather than the supposed hidden ‘root’ causes would result in symptom substitution, that is the problem would re-surface in another form later on. There is little evidence to support this idea. Behaviour therapy also showed that such an outcome, although possible, was very rare.

CBT offers theories about how current problems are being maintained and kept alive and how they can be changed.

The Scientific Principle

CBT offers scientific theories. Scientific theories are designed in a way so they can be tested. CBT has been evaluated rigorously using evidence rather than just clinical anecdote. This is important for a couple of reasons:

· The treatment can be founded on sound and well-established theories.

· Ethically, CBT therapists can have confidence in the therapy they are advocating.

Exercise

List five things that people manage to change about themselves despite doing it badly at first (for example, learning to drive).

1.

2.

3.

4.

5.

List five positive things that you have learned in your life despite experiencing difficulties (for example, moving on from a failed relationship).

1.

2.

3.

4.

5.

Think of an inspirational person who has overcome enormous obstacles by having a powerful and constructive attitude and positive behaviour.

Truth

In CBT we examine our thoughts and behaviours to check if they are realistic. This means we judge and evaluate an event based on facts rather than perception, which can be flawed. Why do you think that, when an accident occurs, the police take statements from a number of people instead of asking just one person what happened?

Truth is about being consistent with reality whilst striving for the goals that are important to you. It's about acknowledging and accepting the existence of the possibilities you dislike while persisting in your efforts to reach your goals.

Exercise

How many ‘F's can you count in the following statement?

FINISHED FILES ARE THE RESULTS OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF MANY YEARS.

Did you see 2 or 3 ‘F's?

There are 6.

I will leave you to find the rest but simply draw your attention to the word ‘of.’

The above is a popular example used to highlight the fact that we don't necessarily see the whole truth. We interpret what we see and experience. What you have learnt from this simple but effective exercise is that your version of the truth can be faulty. It is important to question the truth that you hold about yourself and your ability just in case you are seeing only a few of the good things and missing many others. Sometimes we only see a few ‘F's, when in reality there are more. If the ‘F's represent your positive abilities and qualities, how many of the good qualities are you seeing?

This is just one of the reasons why in CBT we question the validity or reality of our thoughts.

Common sense

In CBT we suggest taking a logical and common-sense approach to thinking.

This does not mean that you become totally unfeeling and emotionless.

Logic or common sense is about the purity of our reasoning skills, whether a conclusion correctly follows a premise or assumption.

For example, which one of these two statements makes sense?

A. Some men shave their heads … therefore anyone with a shaved head is a man.

B. Some men shave their heads … but it doesn't mean everyone with a shaved head is a man.

Clearly statement B makes sense. In statement A, the fact that some men shave their heads does not connect logically to the assumption that anyone with a shaved head is a man. Some women, children and teenagers also have shaved heads.

Logical thinking is useful because we all have the ability to think and use common sense. In CBT, using your common sense well can lead you to form better conclusions about yourself.

Some people think like this about certain goals:

I failed at achieving my goal

therefore, I am a total failure as a person

Others think like this:

I failed at achieving my goal

but that doesn't mean I am a total failure. I am fallible but worthwhile nevertheless. I will learn from my failure and improve.

Which of the above two statements makes sense?

Helpfulness

Finally, in CBT we look at how helpful your thoughts are to you and in the pursuit of your goals. Your thoughts are responsible for how you feel about yourself and your abilities, so it is more helpful for you to have constructive and goal-oriented thoughts than not.

Exercise

Reflect on some thoughts you often have about yourself and your abilities. See if they are helpful to you. For example, you might think ‘I'm not very good at talking in front of people.’

How can you make your thoughts more realistic, logical and helpful? For example, ‘I could improve by facing my fears slowly and gradually.’

Types of Thoughts

In CBT we draw a distinction between different types of thoughts. Not all of our thoughts are involved with our feelings and behaviours. The thoughts that are involved in our feelings tend to have some sort of an assumption or judgement about ourselves, others or the world.

There are two particular types of thought that are involved in our emotions or feelings.

1. Inferences

Inferences are assumptions you make about the things that matter to you, which can be about yourself, others or about the world. For example, if your boss contradicted you during a meeting that was important to you, you might think, ‘he is undermining me’. Then you would be making an inference. This means that in that moment you have gone beyond the facts and made an assumption about what happened because it was significant to you. In this example you would have an emotional response: you might feel annoyed, concerned, anxious, angry or some other negative emotion.

The issue is whether your boss was undermining you or simply expressing a different opinion. In order to find out you would need to gather more information and evidence. Some of our inferences are accurate and some are not. In this ex- ample your inference has not been tested in reality.

If you had thought ‘he has a different opinion, he is not undermining me’ then your emotional response would be different.

Which of the following thoughts will lead to an emotion?

1. I saw a woman getting on a bus.

2. My workmates are ignoring me.

3. I'm a failure.

Thoughts 2 and 3 will lead to an emotional reaction. The second thought is an inference. It may or may not be true. Your colleagues have been ignoring you – they may just have been very busy with work. You need more information to assess the accuracy of conclusion. But if you conclude that you were being ignored then you would have an emotional reaction.

The third thought also leads to an emotional response but it is more profound in its conclusion. ‘I'm a failure’ is an evaluative thought.

2. Evaluations or beliefs

Inferences influence our emotions but do not fully provoke them. Evaluations, on the other hand, are thoughts that are fully involved in provoking emotions and feelings. When you have an evaluative thought you are making a judgement about yourself, about others, or about the world. For simplicity let's call evaluative thoughts ‘beliefs’. These are fundamental in provoking either constructive feelings and helpful behaviours or destructive feelings and sabotaging behaviours.

If you judge yourself as ‘useless’ when you are thinking about applying for a job, this may trigger additional thoughts such as ‘I won't get the job’. When you hold such a belief, you will probably feel anxious when you go for the interview. In a state of anxiety, you will probably not perform as well as you are capable of doing and the likelihood of you getting the job decreases dramatically.

Theory Made Simple

Putting these principles and philosophies into a theoretical model helps you to see more easily how feelings, different thoughts, behaviours and events all interact with one another.

The easiest is the ‘ABC’ model of emotional response.

1. A = Activating Event (or trigger)

2. B = Belief

3. C = Consequences

The ‘A’ can be:

Real or imaginary

The trigger can be an actual event, such as losing someone or something important to you, or an imaginary one. It could also be an inference – a hunch – like imagining that someone is going to reject you before any rejection has taken place.

External or internal

External events are things that happen outside of your body, for example: someone's death, being rejected, failing at something or experiencing an accident.

Internal events are triggers that happen inside your body, for example: your thoughts, images, emotions, fantasies, memories and bodily sensations.

About the past, present or future

The event could be something that has happened in the past, something that is happening now or something that could happen in the future.

Key points to remember:

· ‘A’ can be an internal past event that was real. For example, losing someone you loved. All past events are internal because they exist in our memories.

· ‘A’ can be real, future and external. For example, making a speech at your friend's wedding next week.

· It is not the event itself that provokes your emotions but what you tell yourself or what you infer about it now that provokes your feeling.

· It's easy to assume that A causes C but that would not be accurate.

When the trigger happens at ‘A’, you feel, behave, think and experience symptoms. Because this happens quickly, you think ‘A’ causes ‘C’ (the consequences). So you may use expressions like ‘he made me feel angry’, or ‘my job makes me depressed’. It is as if we are not responsible for our own emotions.

Remember the 100 and 1000 people example earlier?

What is at the heart of your feelings is the ‘B’ (Belief) between ‘A’ and ‘C’. So it is your belief (evaluation) about the activating event that provokes your emotions, behaviours, thoughts and symptoms.

Beliefs

According to the ABC model we can have two types of beliefs: rational and irrational, or healthy and unhealthy.

1. 1. Healthy beliefs:

· are flexible;

· are based on the things that you want, like, desire and prefer;

· tend to make sense – they are logical and consistent with reality;

· mean accepting that sometimes you may not get what you want;

· detach human worth from success or failure;

· lead to emotional well-being and set you up for goal achievement.

2. 2. Unhealthy beliefs:

· are unrealistic;

· can be self-critical;

· are not based on acceptance or acknowledgement of reality;

· do not acknowledge or accept other possibilities (even though reality shows that other possibilities exist);

· cause a mismatch between internal and external realities;

· lead to emotional disturbance and set you up for failure and goal sabotage.

Compare the following statements:

‘I would like it to be nice and sunny every day when I wake up but I accept there is a chance that it might not be.’

‘The day MUST be nice and sunny when I wake up.’

The second example is unhealthy and irrational because it is unrealistic. Unhealthy beliefs do not make logical sense. What makes sense is to have a more healthy belief like: ‘I would like the day to be nice and sunny when I wake up, but it doesn't mean that it HAS to be.’

Healthy negative emotions and self-helping behaviours

It is easy to understand that if you hold a healthy belief about yourself or about certain things in your life, this will increase your chances of success. However, success is never guaranteed, so if you don't succeed you might feel upset and sad. Having healthy beliefs means that, while you might feel sad or upset if you failed, you would lick your wounds, dust yourself off and focus back on your goal. Instead of feeling guilty you might feel regret and look at ways of improving. Instead of feeling unhealthy anger or rage, you might feel annoyed. You would behave assertively without lashing out in a destructive way or giving up. You would believe that you are not a failure as a human being but rather that you are a fallible human being who is able to learn and improve.

Unhealthy negative emotions and self-destructive behaviours

It is not difficult to understand that if you have unhealthy beliefs about yourself and about certain things in your life, your feelings and behaviours are not going to be healthy.

According to the ABC model, unhealthy beliefs provoke unhealthy, negative emotions and self-damaging or destructive behaviours. Depression, anxiety, guilt and rage are examples of unhealthy negative emotions.

ANXIETY VS CONCERN

Unhealthy negative emotion	What the belief is about	Healthy negative emotion
Anxiety	A threat or danger	Concern
How you think		How you think
You exaggerate the overall effect of the threat		You keep the effect of the danger in perspective
You think that you won't be able to deal with the danger		You have a balanced view about your ability to deal with the threat
You see the glass as half empty		You see the whole glass and focus on the full part
Your thoughts are not constructive		Your thoughts are solution-focused and constructive
What you do or want to do		What you do or want to do
Run away physically		Face the threat
Run away mentally		Deal with the potential danger
Do superstitious things to get rid of the threat
Medicate and numb your feelings e.g. with alcohol
Seek assurances from others

DEPRESSION VS SADNESS

Unhealthy negative emotion	What the belief is about	Healthy negative emotion
Depression	Loss or failure	Sadness
How you think		How you think
You only focus on negatives since the loss or failure		You think of both the negatives and positives of the loss or failure
You think of all the other past losses and failures		You do not dwell on past losses and failures
You think you are a failure, helpless		You do not see yourself as a failure or as helpless. You think that you can help yourself to move forward
You think the future is hopeless, bleak and full of misery		You have hope for the future
What you do or want to do		What you do or want to do
You pull away from other people		You express how you feel about your loss or failure
You withdraw into your head		You look after yourself and your environment
You stop looking after yourself and your environment		You engage in healthy behaviours
You get rid of your emotions in destructive ways, e.g. alcohol or overeating

ANGER/RAGE VS ANNOYANCE

Unhealthy negative emotion	What the belief is about	Healthy negative emotion
Anger or rage	Loss or failure	Sadness
How you think		How you think
You exaggerate the actions of the person who has broken your personal rule		You are balanced about the intention behind the thing that was done
You think the other person's intentions were malicious		You don't see malice
You are right and the other person is definitely wrong		You are open to being wrong
You can't see the other person's point of view		You can listen to the other person's point of view
You think of how you can get your revenge		You do not think of seeking revenge
What you do or want to do		What you do or want to do
You physically attack		You talk and behave in an assertive manner but with the right intent
You verbally attack
You pay them back somehow e.g. by ignoring them or staying silent You recruit allies against the other person		You ask the other person to make changes but you don't demand it

HURT VS SORROW

Unhealthy negative emotion	What the belief is about	Healthy negative emotion
Hurt	Someone has treated you badly. You think you deserve to be treated better	Sorrow
How you think		How you think
You exaggerate the unfairness of your treatment		You think in a balanced way about the unfairness
You think the other person does not care about you		You do not think the other person does not care about you
You think of yourself as unlovable or misunderstood		You do not think of yourself as unlovable or misunderstood
You remember the other times when you felt hurt		You don't think about the other times when you felt hurt
The other person must understand and make amends first		You don't insist the other person has to make the first move
What you do or want to do		What you do or want to do
You sulk and shut down		You talk about how you feel in order to persuade the other person to behave more fairly
You pick on the other person without telling them why

GUILT VS REMORSE

Unhealthy negative emotion	What the belief is about	Healthy negative emotion
Guilt	You have broken a moral code or the feelings of a significant person were hurt	Remorse
How you think		How you think
You have definitely committed a sin		You think about what you did and put it in context before you make a judgement
You think you are more responsible than another		You are balanced about your responsibility and the other person's
You forget about how things were		You acknowledged the situation and the circumstances before you did what you did
You deserve punishment		You don't think about retribution
What you do or want to do		What you do or want to do
You escape from your feeling in destructive ways		You face up to the healthy pain
You plead for forgiveness and/or punish yourself by physical deprivation		You ask for forgiveness but you do not physically punish yourself
You make unrealistic promises never to do it again		You make appropriate amends
You deny that you did anything bad		You accept your poor behaviour without making excuses

SHAME VS REGRET

Unhealthy negative emotion	What the belief is about	Healthy negative emotion
Shame or embarrassment	Something shameful has been revealed about you. Other people judge you or shun you	Regret
How you think		How you think
You exaggerate the shameful information revealed		You remain compassionate about yourself. You accept yourself
You exaggerate the likelihood of negative judgement		You are realistic about the likelihood of negative judgement
You think the negative judgement will last a long time		You are realistic about the length of negative judgement
You exaggerate the degree of negative judgement		You are realistic about the degree of negative judgement
What you do or want to do		What you do or want to do
You avoid eye contact with others		You continue participating in social events
You avoid others		You accept others' intervention to restore social harmony
You attack others who have shamed you
You defend your ego in self-defeating ways You ignore others who attempt to help restore balance

UNHEALTHY ENVY VS HEALTHY ENVY

Unhealthy negative emotion	What the belief is about	Healthy negative emotion
Unhealthy envy	Another person has something you find desirable	Healthy envy
How you think		How you think
You devalue the desired object		You admit to yourself that you too desire it
You tell yourself that you don't want it, even if you do		You admit that you'd also want it and accept that you do
You try to attain it, even if it is not useful to you		You find ways to attain it only because you want it
You put other people down and attempt to deprive them of the desired object		You do not put other people down and you allow them to enjoy it
What you do or want to do		What you do or want to do
You belittle the desired object verbally		You do not belittle the desired possession
You belittle the other person verbally		You attempt to attain it but only if you want it
You attempt to remove or deprive the other person from desired possession
You spoil or destroy the desired object or possession

UNHEALTHY JEALOUSY VS HEALTHY JEALOUSY

Unhealthy negative emotion	What the belief is about	Healthy negative emotion
Unhealthy jealousy	There is a potential threat to a relationship from another person	Healthy jealousy
How you think		How you think
You see a threat to your relationship when none exists		You do not see a threat where none exists
You think infidelity will definitely happen		You do not think infidelity will definitely happen
You misinterpret your partner's conversation with and actions towards another as having sexual or romantic meaning		You do not misinterpret your partner's conversation with and actions toward another as having sexual or romantic meaning
What you do or want to do		What you do or want to do
You have visual images of infidelity		You do not have sexual images of your partner with another
If your partner admits to finding someone attractive, you see yourself as less attractive		You accept that your partner can find another attractive without thinking that you are less attractive
You want your partner to only ever think of you		You accept that your partner can see others as attractive just as you can

Exercise

Identify the different emotions in the example below and work out if they are healthy or unhealthy.

Sam is a 40-year-old man and has been married for three years. He is studying towards some professional qualifications and has to sit his final exams in a couple of months. He is finding it difficult to concentrate when he sits down to revise. He keeps thinking that he will fail and, whenever he tries to revise, he ends up doing other work. When his wife tells him to sit down and get on with it he slams his books shut and shouts at her. After his outburst he ends up begging for forgiveness and thinks that he is a bad person.

^*Answer at end of chapter

The following diagram illustrates key points in this chapter.

^* Answer to identifying emotions exercise: Anxiety – unhealthy negative emotion; Anger – unhealthy negative emotion; Guilt – unhealthy negative emotion.