Case Approach to CBT

Case Approach to Cognitive-Behavior Therapy

Assumptions of the Theory
The primary assumptions of cognitive-behavior therapy are that our emotions stem from beliefs, evaluations, interpretations, and reactions to life situations, and that these things contribute to psychological problems. From this perspective, cognitions, emotions, and behaviors interact and are reciprocal in a “cause and effect” relationship. In cognitive-behavior therapy, there is an emphasis on the “here and now” and not the past or the future. With the assumption that one cannot change things that have happened in his or her past, therapy focuses on identifying irrational beliefs and cognitions and learning how to change them into healthy ones. In doing so, one is responsible for his or her own feelings, regardless of what others say or do.

Assessment Techniques
Assessment techniques from the cognitive-behavior perspective are very similar to the behavior therapy perspective. For example, there is a collaborative relationship between the therapist and client, and there is a focus on changing cognitions in order to produce desired changes in behavior and emotion. Also similar to the behavior therapy approach, therapy is time-limited, focuses on specific target problems, and assesses the function of disturbances in the cognitive process.

The first step, however, is to identify irrational beliefs in the client. Using the A-B-C Framework, the therapist and client together can identify the events that cause such beliefs, the beliefs themselves, and also the consequences of these beliefs. In this case, the client may learn to recognize that particular social situations often lead to irrational beliefs. Sometimes the client feels isolated or like she “doesn’t fit it,” and this leads to her believing that she isn’t likeable or that she isn’t “normal” like everyone else supposedly is around her. These irrational beliefs then lead to emotional consequences, such as feelings of inadequacy, low self-esteem, and loneliness.

Another event that leads to irrational beliefs and emotional consequences is spending time with her family. When the client is with her family, she reports having the belief that they are judging her as a person and feels vulnerable. These beliefs lead to a great deal of anxiety and discomfort in the presence of her family. By identifying the activating event/situation, irrational beliefs, and their consequences, the client can next learn to make changes in her cognitions and behaviors.

Goals
In the cognitive-behavior therapy model, therapy is seen as an educational process. As in the assessment process, the client’s first goal should be learning how to identify settings and situations in which she begins to feel uncomfortable. After identifying these situations, the client can identify her irrational beliefs. These beliefs, in addition to those listed above, may include “No one likes me,” “I don’t fit in,” and “No one would miss me if I were gone.” In addition, Ellis identified three irrational beliefs that the client strongly identifies with. These include “I must win the approval of others,” “Others must treat me well,” and “I must get what I want when I want it.” With the help of the therapist, the client will learn that these thoughts are in fact irrational and should be changed in order to become emotionally healthy. Other goals include learning how to separate her evaluation of herself from that of her behaviors. It is very important for the client to learn that her behaviors do not define her as a person OR qualify her as a “good” or “bad” person. It is imperative that the client not only accept herself in spite of her imperfections, but also that she learn to accept others in spite of their imperfections. Doing this may consist of recognizing that although her family may be critical and/or conservative, they still love her and they do have other qualities that make them “good” people. The client also should have a goal of minimizing as many self-defeating thoughts and behaviors as possible. Belittling herself and her worth is not helpful nor healthy. After learning how to alter her thought pattern, the goal is to ultimately alter her behavior, thus also reducing the strength and amount of consequences of those behaviors. For example, by recognizing that others do not judge her the way that she has been believing, she may begin to feel more comfortable in social situations, have a stronger self-esteem, and feel less anxious.

Intervention Methods
One intervention that would be very helpful in this client’s life is implementing the A-B-C Framework, mentioned above. The therapist may give the client a homework assignment that involves identifying specific situations in which the client develops irrational beliefs, what those beliefs are, and finally, what the emotional and behavioral consequences are. After doing so, the therapist may discuss these things with the client and help her to recognize other things that she could think about in similar situations (or disputing the irrational beliefs), or possibly help her to learn how to avoid the situations that lead to the irrational beliefs and consequences. In disputing irrational beliefs, the therapist might suggest replacing “musts” and “shoulds” with preferential language such as “would like.” For example, when the client believes that she must win the approval of others, the therapist may encourage her to believe that she would like to win the approval of others, but it is not absolutely necessary; the world will not end if others do not approve of her.

Other intervention methods the therapist could use include rational emotive therapy, role playing, and shame-attacking exercises. In rational emotive therapy, the client would imagine feeling the way she would like to feel, creating more positive thoughts about herself and her future. Also, she could imagine the worst possible scenario occurring, and the therapist would help her to deal with that, learning that the world would not come to an end in that case, either. For this client, she may imagine being confronted by her family about her actions, which may cause a lot of anxiety. The therapist would help her to realize that despite the confrontation, her family would still love her and she could still love them. This may help to reduce the amount of anxiety she experiences when she is around her family in the future. In role playing, the client may pretend to be in a social situation where the therapist is someone new, and the client may experience the anxiety and discomfort she feels in similar situations in “real life.” However, by role playing, the client can recognize the anxiety she feels and the irrational beliefs she has about being inadequate, allowing her to change those beliefs in a similar “real life” situation. Finally, in shame-attacking exercises, the client would work to feel unashamed even when others disapprove of or seem to be judging her behaviors. In doing so, the client could gain self-confidence and increase her self-acceptance in spite of those behaviors. This may include helping the client to recognize that even though her peers and/or family may not approve of everything she does, she does not have to feel ashamed or guilty.