AN INTRODUCTION TO COGNITIVE BEHAVIOUR THERAPY
AN INTRODUCTION TOCOGNITIVEBEHAVIOURTHERAPYFROM AN REBT PERSPECTIVESimon Simpson
First published in 2014Third edition published 2018Copyright Simon Simpson 2014, 2016, 2018An Introduction to Cognitive-Behaviour Therapy from an REBT PerspectiveThe right of Simon Simpson to be identified as the author of this work has been asserted by him inaccordance with the Copyright, Designs and Patents Act of 1988All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, ortransmitted in any form or by any means without the prior written permission of the copyright owner.Published in 2018 as an electronic book by Simon Simpson, Esher, Surrey, UK
ContentsIntroduction - Why choose CBT?2The cause of the problem: it’s all their fault or maybe not.3Understanding irrational beliefs4The four main types of irrational belief5The four main types of rational belief8Negative emotions: Healthy or Unhealthy?12Naming the emotion13Behaviour14Identifying irrational beliefs15Challenging the irrational beliefs17Strengthen your rational beliefs18Unhelpful thinking19A brief note about your childhood20Practical exercises21Appendix A – Irrational Beliefs and Cognitive Distortions23Appendix B – Thought-Challenging Hint Sheet24Appendix C – Blank ABC Form25Appendix D – Completed ABC Form26Appendix E – Zig-Zag Form27Appendix F - Common Adverse Events and Associated Irrational Beliefs28Further reading29The final word29
INTRODUCTION TO CBTIntroduction - Why choose CBT?Over the past two to three decades, therapies in general, and Cognitive Behaviour Therapy inparticular, have been the subject of many thousands of studies. In these studies CBT hasconsistently been shown to be the most effective therapy for a wide range of concerns. Othertherapies do work, but one of the characteristics of CBT is that clients are helped to learn howto help themselves to feel better, to act in ways that are less self-defeating and to generallyfunction more effectively. Rather than feeling better without understanding how this changecame about, or listening to your therapist impart some nugget of wisdom which suddenlymakes your problems evaporate, in CBT you learn skills that can be applied again and againshould the need arise. You learn how to make yourself less vulnerable to life’s ups and downsand more able to overcome problems should they reoccur.CBT is not one uniform type of therapy that is the same wherever you go or whoever treatsyou. There are a number of slight variations on the CBT theme, all with different names(which are mainly of interest to other therapists but not necessarily of much importance to aclient sitting opposite a therapist). The form of CBT referred to in this booklet is RationalEmotive Behaviour Therapy (REBT) and is the oldest of the CBTs, having been kick-startedinto existence back in the mid-1950s. The ideas in this booklet are mainly based on REBT.A brief note about the examples used in this booklet: these are fictitious examples based onhow people commonly react, and are not intended to represent anyone in particular. simon simpson2
INTRODUCTION TO CBTThe cause of the problem: it’s all their fault or maybe not.The fundamental principle behind CBT is the idea that it is not events themselves that lead toemotional problems but instead it is our attitudes towards events that govern how we react.It is common for people to think that unfortunate events and other people cause them to feelupset. We often hear someone say, "He makes me so angry," or "She made me feel sostupid." The assumption in these statements is that it’s the other person’s fault for how we feel.If it were true that our feelings are directly governed by what happens to us, then everyonewould feel the same way when they get held up in a traffic jam, or short-changed in a shop, orrejected by a lover. But people don’t all react in the same way when these things happen, so itcan’t be the events themselves that cause us to feel angry or anxious, depressed or hurt.Strange as it may seem, it is our own beliefs and attitudes that cause us to feel distressed. Toillustrate this, take the following example of public speaking, suggested by psychologist PeterTrower: Three speakers give speeches that are equally well received by the audience. Onespeaker might notice the applause and be pleased with her performance. The second speakermight feel depressed because she thought that the audience was only clapping to be polite,and that they were actually bored. The third speaker might feel angry because she had put agreat deal of effort into preparing the speech and she thought the audience was not sufficientlyappreciative. With this example it can be clearly seen that the same event may lead to a rangeof different emotions, depending on how the event is interpreted.The fact that our beliefs and attitudes govern our feelings is good news. Why?. becausealthough we may not always be able to choose how people treat us and what happens to us,we can choose how we respond.The realisation that the way we think affects how we feel is not a new idea. In the first centuryAD the Roman stoic philosopher Epictetus said, "Men are disturbed not by things but by theviews which they take of them." And as Shakespeare wrote in Hamlet, "There is nothing goodor bad but thinking makes it so."Despite these ideas having been around for a long time it wasn’t until the 1950s that they wereproperly integrated in psychotherapy with the work of the American Psychologist, Albert Ellis,who developed an approach now referred to as Rational Emotive Behaviour Therapy(REBT). Ten years later in the 1960s Aaron Beck published similar ideas under the label ofCognitive Therapy, and Cognitive Behaviour Therapy as we know it today was born.In the years since Ellis and Beck developed REBT and Cognitive Therapy psychologists havemade further refinements to the techniques, giving additional attention to the profound effectthat our behaviour has on how we feel. These behavioural aspects of therapy are touched onlater in this booklet. simon simpson3
INTRODUCTION TO CBTUnderstanding irrational beliefsOur emotional state can be affected by various things in addition to our thoughts; a smellmight uplift us (freshly baked bread perhaps), a piece of music might soothe us, doing someexercise might invigorate us. However, whilst these sorts of things have some short-term effecton our mood the most sustainable way to control our emotions is to change our beliefs andattitudes.As mentioned in the previous section, in any given situation the way we feel emotionally willbe governed by our beliefs about the situation; if our beliefs are rational and appropriate to thesituation we experience appropriate healthy emotions. If our beliefs are irrational andinappropriate we experience inappropriate unhealthy emotions (there is more about this onpage 12). The term ‘rational’ can be a bit off-putting for both therapists and clients as it carriesovertones of being rather intellectually aloof or judgemental. It is not meant this way and theterm simply refers to a belief that is unrealistic, illogical or which does not get us good results.Perhaps a more acceptable term is ‘unhealthy’ belief.CBT holds the idea that we often misinterpret the events around us in various ways: perhapsby exaggerating the likelihood of something bad happening, or perhaps by paying selectiveattention to things or by taking things personally. Most of the time challenging these kinds ofmisperceptions is sufficient to bring about positive changes in people’s lives. However, inaddition to looking at these sorts of negative thoughts which seem to happen automatically weshould also look at why you might be prone to these misinterpretations. The reason this isimportant is because our negative assumptions or misinterpretations do not arise out of thinair; in fact they stem from holding a number of more deep-seated unhealthy attitudes. Theseunhealthy attitudes are referred to as irrational beliefs and there are four main ones: Demands,Awfulising, Discomfort Intolerance, and Self-Depreciation. A Demand is an inflexible rule that we hold about how things should be (e.g. “I must not belate for my appointment.”). When our rules or demands get broken we are liable tobecome very distressed. Secondly, when our demands are broken we tend to take an extreme view of the situation(Awfulising). For example, instead of viewing it as bad if you are late for an appointmentyou see it as absolutely catastrophic, literally the worst possible thing that could happen. Thirdly, Discomfort Intolerance beliefs lead you see the situation as totally unacceptable,something you tell yourself you cannot stand or cannot tolerate. Finally, Self-depreciation beliefs are ones where you put yourself down, labelling yourself as acomplete failure or completely stupid or totally unlikable. You may also do this for otherpeople (other-depreciation) or for life in general (life-depreciation).These four beliefs are examined in more detail in the next section. simon simpson4
INTRODUCTION TO CBTThe four main types of irrational beliefDemandsAll of us have hopes and desires. These desires are an important factor in our lives, driving usto improve our own lives and the lives of those around us. However, Albert Ellis proposed thenotion that it is a human characteristic for us to tend to escalate our most important desiresfrom being simple wishes or wants to being things we think we absolutely must have. Forinstance rather than simply wanting to avoid being rejected by a lover we might tell ourselveswe must not be rejected, that it just cannot be allowed to happen. Or because we do not wantto disappoint our parents we might think that we absolutely have to get the highest grades inall our exams. Ellis called this our innate tendency to irrationality. By this he meant that eventhough it is not a healthy thing for us to do, we are very likely to fall into the trap ofdeveloping inflexible rules or demands for how we should behave. We are also prone to do thesame for how other people should treat us, and for how the world around us should be.Of course, even the most distressed person doesn’t hold these extreme and demanding beliefsabout everything. However, if you find your thoughts and speech are peppered with wordslike must, have to, got to, must not, and cannot, then there’s a high likelihood that you are holdingdemanding beliefs.AwfulisingIf we hold the kinds of dogmatic and inflexible rules or demands described above, then whenthose demands are not met we are almost inevitably going to evaluate the situation in anextreme and exaggerated way. Awfulising, in this context refers to viewing the situation aspretty much the worst thing that could happen. Literally, 100 per cent bad. We tend to jumpto this extreme position because if we are holding an ‘all-or-nothing’ demand about what musthappen, we are going to find it nigh-on impossible to accept that things have not gone the waythey should have. It is a bit like letting go of a ball at the base of a slope and finding the ballrolls uphill. It simply isn’t something we can comprehend. With our demanding beliefs wehave a fixed view of how things must be and anything that breaks these conditions is seen asbeing incomprehensibly bad.Discomfort intoleranceDiscomfort intolerance is sometimes referred to as Low Frustration Tolerance (LFT) and inthis sense means we have a very low threshold for tolerating our desires being thwarted,frustrated or blocked. It is another form of extreme thinking that stems from holding inflexibledemands – in this case about whether things should go our way or about how comfortable lifeshould be. Albert Ellis summed up these beliefs with the rather snappy phrase of, ‘catching adose of I can’t stand it-it is.’ (Ellis liked introducing humour into his work – not to poke fun at simon simpson5
INTRODUCTION TO CBThis patients but to help people take themselves and their unhelpful thinking less seriously. Tomisquote Epictetus, if you can laugh at yourself you will never run out of jokes).This LFT belief is apparent when for instance we eat a large slice of cake despite trying to loseweight. In this case we might be holding the belief that we cannot stand the idea of missingout on the enjoyment of eating the cake, or the belief that we cannot stand the discomfort ofresisting the temptation. Similarly LFT beliefs might be at play when we put off writing abooklet about CBT believing that we have to be in the right mood and we cannot tolerate thediscomfort of doing something that seems uncomfortably like hard work.Self-depreciationAlso referred to as self-downing, self-depreciation is when we put ourselves down in some wayand, like Awfulising and LFT, tends to arise when we fail to meet a self-imposed demand. Inthe case of self-downing the demands are usually about our own performance. For example ifyou give in to the temptation to eat a chocolate bar despite trying to lose weight, you mightconclude that breaking your rule of avoiding chocolate means you are a weak person. Othercommon examples can be seen with parents of young children: because most people thinkthey have to be caring parents, they might see themselves as being useless or failures asparents when they lose their temper. Self-depreciation should not be confused with being selfdeprecating which is a term used to describe when we are being humble; self-depreciation iswhen we really beat ourselves up over failing to do something that we believe is nonnegotiable. We over-identify with our shortcomings and think that these shortcomings sum upour whole character.Self-depreciation also kicks in when we base our self worth on aspects of ourselves that mightchange over time or on certain status symbols such as wealth, looking youthful or having a jobthat we consider is worthy and important. A desire to have wealth, or an enjoyment of beingyouthful or of finding satisfaction in doing a well-esteemed job are not bad things, and it isgood that we all want different things in life. Where these desires become unhealthy is whenwe base our self-worth on these factors. It is unhealthy because by investing your self-worth inthings that may change you are likely to experience a crash in your self-esteem if you wereever to lose those things. If you think that you are a worthwhile person because you lookyoung, how would you feel about the prospect of growing old? We would be well advised towatch out for thinking that we have to look young or that we have to have a high-powered job,or lots of friends, or so on, and the faulty conclusion that if we do not have these things itmeans we are worthless.This sort of damnation is not only confined to ourselves: we can be damning of other peopletoo. We can easily fall into the trap of labelling people who do things we believe should not bedone: People who push in front of us in a queue, or people who let their dogs foul thepavement might be labelled as idiots or inconsiderate fools (or worse, usually). simon simpson6
INTRODUCTION TO CBTWe can even be damning of the world around us and of the future, such as when we say,‘People shouldn’t endure hardship or suffering unfairly, and the fact that there are floods andearthquakes shows the world is a cruel place.’ Or, ‘I failed to get the job I applied for. I had toget it and now my future is ruined.’These four main types of irrational or unhelpful beliefs have healthy and rational alternatives.These are discussed in the next section. simon simpson7
INTRODUCTION TO CBTThe four main types of rational beliefPreferencesDemands have their equivalent healthy or rational alternative, referred to as preferences. Theprincipal characteristic of preferences is that they are flexible and realistic attitudes towardslife. They are flexible because we acknowledge that we do not always get what we want:sometime we do, sometimes we do not. They are realistic because the sad reality is that we donot always get what we want.One of the leading CBT/REBT psychotherapists in the UK, Dr Windy Dryden states that itis important to note that rigid, demanding beliefs share the same starting point as flexible,adaptive beliefs: in both instances the person starts from the position of wanting or notwanting something to happen. With unhealthy rigid demands the person goes on to tellthemselves that because they do not want the thing to happen then it must not happen. Forexample they might say to themself that because they do not want to fall ill just before goingon holiday, that they must not fall ill. The person with the healthy, flexible belief starts fromthe same idea that they do not want to fall ill before going on the holiday of a lifetime, butthey also acknowledge that there is a possibility it might happen.The challenge is to identify when our flexible desires inadvertently become turned intosomething more extreme, and when we start to think in terms of ‘must haves’. When wenotice this happen then we can usually understand the extreme and unrealistic nature of ourthinking: that just because we want something, this does not mean we will automatically get it.It is pretty clear that even though we might not want to fall ill before a holiday, there is noguarantee that it cannot or will not happen.Anti-awfulisingWe have already seen that awfulising beliefs are those in which we view a situation as theworst situation imaginable. In this sense life becomes like walking along a tightrope: there isonly one direction to go, with no possibility of deviating from this linear course. Unlike apedestrian who, when bumped into, might stumble but be able to get up again (bad but notcatastrophic), if we fall or get knocked off our tightrope the results are very bad indeed.Holding flexible beliefs about the possibility of negative events happening is a bit like walkingon the pavement rather than on a tightrope: we can see that if the negative event happens itmight be bad but there are plenty of events that could be a great deal worse. In WindyDryden’s book ‘Ten Steps to Positive Living’ he quotes Albert Ellis who gave a lecture andsaid that probably the worst thing that could happen is being run over by a steamroller. Abright spark in the audience made the comment that the situation could in fact be worse – thesteamroller could be going very slowly. This is a rather light-hearted remark but the pointbeing made is that however terrible the situation seems there is likely to be something thatcould be worse. Understanding this helps us to gain a degree of perspective about the badthings we experience. We can acknowledge that the situation is bad but not the worst thing simon simpson8
INTRODUCTION TO CBTthat could happen. Windy Dryden likes to cite the singer Smokey Robinson’s mother who toldher son, “From the day you are born, till you ride in the hearse, ain’t nothing so bad that itcannot be worse.”Discomfort ToleranceDiscomfort tolerance (as opposed to intolerance), also referred to as High FrustrationTolerance (HFT) relates to the nature of the hardships we face and to our ability to live withthat hardship.As discussed previously, with discomfort intolerance, or LFT, we tell ourselves that we cannotstand the discomfort or inconvenience of a situation, and that we cannot live with such a stateof affairs. However, as with the Smokey Robinson quote about anti-awfulising, logically wecan tolerate or live with anything up to the point at which it stops us from living. This mayseem a rather extreme position, but at its most basic level a high frustration tolerance (HFT)belief is one which reflects that however bad a situation might seem, as long as we are alive,we are tolerating it. Tolerating does not mean liking; when we tolerate a situation we may notlike it, but we do live with it. In many cases the adverse situation is temporary or will changeover time, but even in situations where the adversity is not
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