Cognitive Behavior Therapy, Second Edition - Basics and Beyond" by Judith S. Beck, and Aaron T. Beck

0:00 [Music] All right, welcome to the deep dive. Today we're going to be tackling CBT. I think a lot of people have heard of it, but we're going to be getting into it a little bit deeper today. Um I think it's safe to say that it's one of the most popular um therapies available and also very effective and well researched. Yeah, absolutely. I think it's interesting how um CBT really goes beyond just the therapy room. These are skills and concepts and tools that we can use in our everyday life. When you think about how we understand the connection between our thoughts and our feelings and then ultimately our behavior that can be really applicable outside of just a therapist's office. Yeah, absolutely. I mean, I've heard it described as a mental workout. You know, it's giving your brain a workout. Yeah.

0:46 And I think one of the things I really appreciate about CBT is this idea that, you know, it's not just about some expert coming in and telling you what's wrong with you or diagnosing you or telling you what to do. It really is about empowering you to gain a deeper understanding of your own mental processes. Yeah. You know, when you're faced with difficult situations or challenges or just the ups and downs of life, CBT can really give you that toolkit to navigate those things a little bit better. Yeah. I think it's that self-awareness, you know, understanding how those patterns work, where they came from, and how they're affecting you. So, yeah, we're going to go a bit deeper in this deep dive. We're going to be talking about a lot. We're going to be going over the origins of CBT, some of the core principles, what a session actually looks like, so you get a feel

1:31 for that, and then some of the actual techniques. So, for those of you listening who might be new to this, maybe haven't really delved into the world of CBT, just as a quick overview, you know, we're going to break down the essentials, give you those real aha moments from the research and foundational texts without weighing you down with a bunch of psycho babble, you know, just keeping it straightforward and understandable. Yeah. So, let's get into it. the genesis, the origin story of CBT and it all starts with a guy named Dr. Aaron Tbeck. Now Beck, what's interesting is that he was initially trying to validate some core ideas in psychoanalysis. He wasn't trying to develop a new therapy at all, right? So he's starting within that existing theoretical framework which at the time was pretty dominant, right? He was and one of those ideas is that depression is

2:18 basically hostility turned inwards. So he had this hypothesis. He's like, "Okay, well, if that's true, then the dreams of depressed people should contain themes of anger more so than the dreams of people who are not depressed." So, he's using dream analysis, kind of a classic psychoanalytic technique to try to prove this. Absolutely. He's putting it to the test, being scientific about it. But here's where things took a huge turn. His findings did not support his expectation at all. A classic example of how science works. Sometimes those unexpected findings really change the game. So, what did he find? Instead of anger, he found that the dreams of these depressed patients were really dominated by themes of defectiveness. You know, feeling inadequate, deprived, and a sense of loss. Okay, so lost

3:05 effectiveness. It's starting to sound familiar, right? It's starting to line up with what we might expect, right? It's already starting to challenge that initial understanding of depression as just anger turned inwards, right? And then he makes another really crucial observation. He notices this really striking similarity between those themes from the dreams, loss, deprivation, defectiveness, and the thoughts that his patients were reporting when they were awake. So he's seeing this connection between the unconscious, you know, what's going on in the dreams and their conscious thoughts and experiences. Exactly. And this was a gamecher. It's suggesting that these conscious thought processes are playing a much bigger role in depression than maybe psychoanalysis had previously considered. Yeah. And this wasn't just one study either. Beck continued to challenge those

3:51 psychoanalytic ideas. He even challenged this notion, which again was pretty prevalent at the time, that people with depression somehow needed to suffer, which sounds a bit odd when you say it out loud. Yeah. And you know, as you're saying it, it's just like that doesn't seem to make a whole lot of sense, does it? Well, and that's why Beck's research was so significant. He's gathering evidence. He's looking at what's actually happening and he's challenging these assumptions. And what he found really suggested that this idea of people needing to suffer wasn't really accurate. Right? So all of this is saying that, you know, if these core ideas about depression weren't quite right, then how else can we understand it? And that's what paved the way for CBT to emerge. This whole new way of thinking about approaching and addressing emotional difficulties, starting with a recognition that our

4:37 thoughts play a huge role. And that's what CBT is all about, right? understanding how those thoughts, our interpretations, our beliefs shape how we feel and how we act. Right? And that brings us to some of those core principles that guide CBT. And one of the first, and you see this in every CBT text, is this idea of individualized conceptualization? So, what does that really mean for you? You know, someone who's maybe considering CBT, what does that mean for you? It means CBT isn't a one-sizefits-all approach. It really is about understanding your specific problems and then developing a cognitive conceptualization that's completely tailored to you. Okay. So, I'm hearing it's not a one-sizefits-all. It's tailored to you. Right. Absolutely. And to illustrate this, our source goes into an example with a woman named Sally and how a therapist might think about her

5:23 case. Can you walk us through that? Yeah, absolutely. So, when thinking about Sally and her challenges, the therapist would actually consider three different time frames. Okay. Three different time frames. Yeah. So the first one is Sally's current thinking. So what are the kinds of thoughts that are popping up for her? What's contributing to her feeling so sad or down? So what are some examples of those thoughts? What might Sally be thinking? So she might be thinking things like, "I'm a failure. I can't do anything right. No one likes me. I'll never be happy." Those kinds of really negative, really self-critical thoughts. And then alongside those thoughts, the therapist would also want to look at what Sally is currently doing or perhaps not doing. So that's the behavioral side of it. Exactly. So is she isolating

6:10 herself from friends? Is she avoiding asking for help when she needs it? Those kinds of things. Avoiding things that maybe she used to enjoy or that she knows in the long run would probably be helpful, but she's just avoiding. Exactly. And it's important to note that these thoughts and these behaviors are often really intertwined. You know, the thoughts feed the behaviors and the behaviors can feed the thoughts kind of creating this negative cycle, right? A downward spiral. Exactly. Yeah, that makes sense. Now, the second time frame you mentioned was what was it? The precipitating factors. So, what might have triggered or made Sally's depression worse? So, what was going on in her life when these things really started to intensify or become a problem? Exactly. So in her case, she had recently moved away from home for

6:55 the first time and she was struggling with her academic work. Both of those things were really contributing to her belief that she was incompetent, that she couldn't handle things on her own. Okay, so kind of some external stressors that then are feeding into these internal beliefs. Right? So being away from that familiar support system and then facing challenges that she's maybe not used to can really trigger those negative beliefs. So that's the second time frame. And then the third one, what's that? The predisposing developmental factors. So, this is really about starting to understand, you know, what are some of the key childhood experiences that might have made Sally more vulnerable to depression now as an adult? What are some of those lasting ways of understanding or interpreting the world that go all the way back?

7:41 Right. Kind of the deeper roots of these patterns that have been with her for a while. Exactly. So in Sally's case, it came out that she had a tendency to attribute any of her successes to just being lucky. Oh, so like externalizing the good, right? She's not taking ownership of those successes. But then when she experiences any kind of setback or failure, she really internalizes that, right? Like she sees it as proof that she's not good enough. Exactly. Like those weaknesses or failures really reflected her true self, which is a pretty painful way to see yourself and the world. Yeah. Absolutely. So, by looking at these three time frames, current thinking and behavior, triggering events, and those past developmental influences, you're getting a much richer picture, a more holistic picture of Sally's experience. Absolutely. It's not just, okay, what

8:27 are you thinking right now? It's also, well, what happened recently that might have made things worse and what happened way back that might be contributing to your vulnerability to this, right? So, it's a much more nuanced and indepth understanding of what's going on with you, Sally. Now let's go to another core principle and it emphasizes that CBT goes beyond just talking. It's about using a whole range of techniques, right? So it's not just sitting on a couch and talking about your childhood, right? Yeah. It can get a little more active than that. So what are some of those techniques? So while cognitive strategies like Socratic questioning and guided discovery where the therapist is really helping you to come to your own conclusions by asking you questions, those are really central. There's also behavioral techniques, problem solving techniques, and interestingly, you know,

9:14 a therapist might even use techniques from other therapies like gestalt therapy or psychonamic approaches as long as they fit within that cognitive understanding of how thoughts, feelings, and behaviors all interact. Right. So, it can draw on different traditions, but it's always through that CBT lens. Exactly. Okay. So, it's not just one thing. No, it's a very diverse toolbox and the choice of which technique to use really depends on that individual understanding that we just talked about. What's the specific problem that you're working on and what's the objective for this session? It's very much tailored to what's going on with you and what your needs are. Okay, so we've gotten a good sense of, you know, where it came from, some of the guiding principles, but let's get into, you know, what does this actually look like? What does a session look like? You know, what can you

10:00 expect? what happens in that room. So, a typical CBT session will follow a pretty clear structure. It usually starts with reestablishing the therapeutic alliance, which is really that feeling of trust and working together, you and the therapist. Then there's usually a check-in on your mood. You know, how are you feeling? Are you experiencing any symptoms? And what are some of the key things that have happened since the last session? So, it's just kind of an update on how things have been going for you. Exactly. you know, giving the therapist that context of what's been happening in your life. Okay? And then after that, a key part is agenda setting. The therapist will work with you to identify the specific problems that you most want to focus on during that session. These

10:45 might be issues that came up during the week or challenges that you're anticipating in the week ahead. So, you actually have a say in what the session's about. Absolutely. It's very collaborative. You're not just passively listening to the therapist tell you what to do. You have a voice in what you want to work on. Okay. So, I'm hearing collaboration. You're actively involved in the session. Exactly. And then the session will also involve reviewing any self-help activities or homework that you agreed to do since your last session. Okay. So, those action steps that you're taking outside of therapy, making sure that those are on track, right? And then after that, you'll really dive into one of the problems that's on the agenda. Okay. So, now you're getting into the nitty-gritty. Exactly. Yeah. So during that part, the therapist will help you gather information about the problem. So they

11:31 might ask about the specific thoughts, emotions, and behaviors that are connected to it. And then using all of that information, you and the therapist will collaboratively plan a strategy to address the problem. And those strategies can vary, right? Depending on the issue, the person, what they're working on. Absolutely. It might be a straightforward problem solving approach. It might be that there's some negative thinking that's fueling the problem. So you might need to look at that. Or it might be about planning specific steps to change your behavior in a certain situation, right? And our source gives us an example with Sally who's having difficulty studying, right? How might a session address that specific issue for her? Yeah. So the therapist might first focus on addressing Sally's negative thoughts about studying. So she might be saying things like, "What's the point? I'm

12:17 probably going to fail anyway." H the goal would be to help Sally develop a more balanced and realistic way of looking at that situation. So it's challenging that black and white thinking. Exactly. Okay. Yeah, that makes sense. And then what what would the therapist do? And then they might work together to come up with practical steps that Sally can take to make studying a little bit easier and more manageable. So, breaking down those big study tasks into smaller chunks, summarizing the material as she reads, taking regular breaks, and maybe even reaching out to her teaching assistant if she's feeling stuck. Okay? So, it's getting concrete actionable steps that she can take. So, it's this understanding those thought patterns that are affecting you and then coming up with these really concrete things that you can do to actually address the issue. Exactly. And the source emphasizes that after discussing that

13:04 one problem and setting some homework, the therapist and Sally would probably move on to another item on the agenda and go through a similar process. And then at the end of the session, there's always a review just to tie everything together to make sure that the homework assignments are clear and that Sally feels confident that she can do them. And a really important part is the therapist actively asking for Sally's feedback about how the session went for her. Right? So you have a chance to say what was helpful, what wasn't, what you'd like to focus on next time, that kind of thing. Exactly. It's a really important loop because it makes sure that the therapy is actually meeting your needs and addressing what's important to you. Yeah. It's a collaboration. Now, for those of you listening, you might be thinking, "Well, this sounds pretty simple, right? I could do this." And you know what? It

13:50 can sound simpler than it actually is in practice. Especially for those of you who might be interested in becoming CBT therapists yourselves, you know, our source has a word of caution there. Yeah, definitely. I mean, the core idea that our thoughts influence our emotions and behavior. Yeah, that's pretty straightforward. You know, that makes sense. But experienced CBT therapists when they're in that room with you, they're actually managing a lot of really complex things all at the same time. Like what, you know, what's going through their head? So, while they're listening to you, while they're responding to you, they're constantly forming an understanding of your situation. They're building rapport with you. They're educating you about CBT. They're identifying specific problems that you're bringing up. They're gathering information, they're testing

14:36 out hypotheses about your thinking, and then they're summarizing those key insights for you. It sounds like they're juggling, like they're at a circus. It can feel like that. M and the source points out that new therapists often need to be much more deliberate and structured. You know, they might focus on just a few elements at a time while they're learning, right? So, it's a skill. It takes time. You know, you get better at it with practice. Absolutely. Yeah. It's not something you can just pick up and be great at right away. And, you know, even for someone who's learning CBT, you know, not necessarily as a therapist, but just for themselves, our source actually brings this up. You know, you might have some automatic thoughts pop up about it like this is too hard. I'm not going to get this. What if it doesn't work for me? What if I can't do this? Yeah. Yeah. And you

15:22 know what? The advice that our source gives is very CBT oriented. Okay. So, how do they suggest you deal with that? They suggest that you actually notice those thoughts, write them down, and then refocus back to the material. And they even tell you to check out those sections on how to evaluate and respond to those thoughts. So, you're kind of using CBT to learn about CBT, right? You're applying it to your own learning process. Exactly. Exactly. So, it's a meta level. Now, our source emphasizes that good basic counseling skills like building rapport, showing empathy, actively listening, those are essential for effective CBT. Absolutely. So, it's not just about the techniques, it's about the human connection. It's about the therapist's skill in building that relationship with you and understanding your perspective and really guiding you

16:07 through the process in a way that feels safe and supportive. Right. And so that might mean, you know, thoughtful questions, reflecting back what you said to show that they're listening, statements that validate and normalize your experience. So showing empathy is not just about saying, "Oh, I understand." Right. Right. It's about actions. It's about the way that they respond and the things that they actually say. And then that continuous feedback that we talked about earlier, you know, how is that really utilized effectively by the therapist? So, a skilled therapist, they're always paying attention to your reactions, your facial expressions, your body language, even just subtle changes in your tone of voice. And if they notice any signs of distress, they'll address it directly. So, they might say something like, you

16:53 know, you seem upset right now. What's going through your mind? Right? Or, you know, they might notice that you're hesitant to say something and they'll say, you know, it seems like there's something you want to say, but you're holding back. What is it? And it's important that they acknowledge your feedback even if it's negative, you know, even if it's critical because that's you telling them what's working and what's not. Exactly. And that gives them a chance to understand the problem from your perspective and to work together to find a solution. And it's important to create that safe space for you to be honest. Right. Because if you don't feel comfortable sharing those things and it's going to affect how helpful therapy is. Absolutely. And even when the relationship feels really strong, it's still important for the therapist to actively solicit feedback

17:38 at the end of every session. You know, how did you feel about the session today? Was there anything that didn't sit quite right with you? Anything you'd like to do differently next time? Yeah. So, it's that open communication. It's that sense that your voice really matters and that they want to hear what you have to say. Exactly. And you know, ultimately, one of the most powerful ways to build that relationship is by being a helpful and skilled CBT therapist because the research shows that the better the therapy is going and the more your symptoms reduce, the stronger that connection between you and the therapist tends to become. It's a positive feedback loop in a way, right? Okay. So, let's move on now to really bring some of this stuff to life. You know, our source provides an example, a little snippet of a therapist working with Sally on a specific problem, and

18:24 the problem is she's having trouble finding a part-time job. So, can we look at how that conversation actually plays out? Yeah, definitely. So, the therapist starts by acknowledging the difficulty that Sally is having and then the therapist says, you know, what's going through your mind right now? So, they're already trying to identify what are those automatic thoughts that are popping up in relation to this problem. Yeah. Getting right to those thoughts. And Sally responds, "I won't be able to handle a job." And the therapist labels it, you know, she says, "That's a thought." And how does that thought make you feel? Right? Connecting it to the emotion, right? So it's not just, "Oh, that's too bad." But it's like, "No, how's that actually making you feel?" Right? What's the impact of that thought? And Sally responds, "Well, it makes me feel sad. It makes me feel discouraged." Yeah. You know, and the therapist then begins to gently evaluate

19:13 that thought. So she asks, "What's the evidence that you won't be able to handle working?" So looking for proof, right? And Sally brings up, you know, that she's been struggling to keep up with her classes. She's been feeling really tired. But then the therapist offers a little bit of a reframe. You know, maybe looking for a job is actually harder than actually doing a job, especially one that you already have some experience with. It's kind of reframing it, looking at it from a different angle. Exactly. And then she asks, "Is there any other evidence that you wouldn't be able to handle a job?" Keep digging. Tell me more. Right. And Sally then acknowledges, "Well, actually, I did work last year while going to school, so I guess I was able to manage it then." So, she's finding some evidence that contradicts her initial thought. Exactly. So, she's like, "Wait a minute, maybe I'm not

19:58 doomed." Right. And the therapist keeps exploring. She asks, "Is there any evidence that you could handle the job?" And then Sally's like, "Well, maybe I could do something that doesn't take up too much time that's not too demanding. You know, I did that sales job before. Maybe I could do that again." Yeah. And they continue to explore those possibilities, like working at the university bookstore. So, in this short exchange, you can really see that process of identifying the automatic thought, linking it to the emotion, looking at evidence for and against it, and then starting to brainstorm some potential solutions. Right? And it's done in such a collaborative, non-judgmental way. you know, she doesn't say, "Oh, Sally, that's ridiculous. You're being silly." Right. It's really about gently guiding her to see things in a new light, you know, and also to take those concrete steps to

20:44 address the problem. Exactly. Exactly. And this brings us to another key aspect of CBT, especially when you're dealing with depression, this emphasis on the positive. Right. And our source emphasizes that, you know, people with depression often have a tendency to focus on the negative, which makes sense. You know, when you're feeling depressed, that's kind of where your attention goes, right? The world seems more negative. You're picking out more of the negative things. Exactly. And so, they might, you know, automatically pay attention to the negative experiences, give those a lot of weight, and they might completely overlook or not even notice more positive experiences. It's like having blinders on to the positive. Exactly. You're just not seeing it. Okay. And so, you know, this can lead to a distorted view of reality. you're not seeing things accurately. You're not

21:30 seeing the full picture. And to help with this, a CBT therapist is going to consistently work with you to notice and attend to more of the positive aspects of your experiences. So, it's not about faking happiness. It's not about, you know, just putting on a smile and pretending everything's okay. Right. Right. It's not about toxic positivity. It's about bringing balance. Exactly. It's about helping you recognize and acknowledge those positive moments, those achievements, those things that are going well that you might otherwise miss. Yeah. Because if you're only focusing on the negative, it's hard to see that there's any good in your life. Absolutely right. Okay. So, now let's talk about homework. You know, because therapy doesn't just happen in the therapy room, it's also what you're doing outside of that time. And our

22:15 source really emphasizes that, you know, a goal of treatment is to help people feel better by the end of the session and to set them up for a better week. And homework plays a key role in that. Right. Right. Because you want to be able to take what you're learning in therapy and actually apply it in your everyday life. Okay. So, what are some of the typical goals of homework? So, there are usually three main goals. The first is to help you evaluate and respond to those automatic thoughts that are likely to come up between sessions. So, not just waiting until you see the therapist again, but starting to notice them and work with them as they arise. Right. Right. So, you're becoming more aware of them and you're starting to challenge them using the techniques that you're learning in therapy. The second goal is to encourage you to actually devise and implement solutions to the

23:01 problems that you're working on. So, it's putting those solutions into practice, right? Not just talking about them. Exactly. And then the third goal is to give you opportunities to practice new skills, right? So, if you're learning a new coping skill, you know, a way to manage anxiety or a way to communicate more effectively, homework gives you a chance to actually try that out in real life. And it's important to remember to actually write down those homework assignments because it can be easy to forget the details when you get home. So, having it written down in a therapy notebook or on a form that the therapist gives you can be really helpful. Absolutely. And our source points out that, you know, there are specific times when those automatic thoughts are most likely to occur for you between sessions, like when might those be? So, they're most likely to pop up when you're starting to feel down or

23:47 distressed, when you feel the urge to do things that you know aren't helpful in the long run, or when you notice upsetting changes in your body or your mind. So those are the times to be extra vigilant to really pay attention to those thoughts and be ready to use those CBT tools. Now our source also points out that you know we all do a certain level of automatic reality checking without even realizing it. Yeah. It's like our brain's natural defense mechanism. So what's an example of that? So let's say you have the thought, I'm never going to finish this project. It's just too overwhelming. I think we've all been there. Yeah. Right. But then you know your brain might chime in and say wait a minute. remember that other time you finished that really big project? Even though it felt just as daunting, you got it done. And so you're kind of

24:33 naturally challenging that negative thought, right? You're reminding yourself of your own capacity to do things even when they seem difficult. Exactly. And often when we look at those thoughts objectively, it leads to positive changes in how we feel, what we do, and even our physical reactions. So we're already doing some of the CBT stuff without even knowing it. Exactly. But CBT helps you do it more consciously and more effectively. Now, this brings us to the concept of beliefs. Where do those automatic thoughts even come from? And our source explains that starting in childhood, people develop certain fundamental ideas, beliefs about themselves, about other people, and about the world around them. Yeah. And these beliefs really shape how we see the world, how we interpret our experiences. And what's

25:19 interesting is that these core beliefs, these deep-seated understandings, they can feel so true, so fundamental that we're often not even consciously aware of them, right? It's just how things are. You know, it's like this is reality. This is how the world works. And our source gives an example of a reader E. And reader E is reading the text about CBT. And reader E feels too unintelligent to really understand it. And the same worry comes up for reader E whenever they're faced with a new task or a new challenge. And the source suggests that reader E might have this core belief of I'm incompetent. Yeah. So that underlying belief that I'm not good enough, I can't do it. Right. And you know that belief gets activated in different situations and it acts like a filter through which they see the world

26:04 and interpret their experiences even if that interpretation doesn't really line up with reality. Right? So in reader E's case, even if the material isn't actually that difficult, that belief is going to make it seem way harder because they're seeing it through that lens of I'm not smart enough to understand this, right? So it's coloring their perception of the situation and then leading to those feelings of discouragement and inadequacy. And this leads us to a cognitive conceptualization. You know, the source gives a diagram for reader E that shows this whole hierarchy of these beliefs, right? So it's not just one belief, it's this whole system of beliefs that all connect and interact. Okay. So can you walk us through that hierarchy for reader E? Yeah. So at the very deepest level for reader E, there's that core belief. I'm

26:49 incompetent. And then out of that core belief grows a whole set of intermediate beliefs. Okay, intermediate beliefs. So those are the ones that are a little bit closer to the surface, right? And these might include things like an attitude. So for reader E, it's it's terrible to fail. Okay. And then a rule. So if a challenge seems too great, I should just give up. And then some assumptions. So if I tried to do something difficult, I'm going to fail. But if I avoid it, then I'll be okay. So you have the core belief, the attitude, the rule, the assumptions, and then what? And then when reader E encounters a specific situation like trying to read a new text, those underlying beliefs, they trigger those automatic thoughts. So in this case, the thoughts might be, "This is just too hard. I'm so dumb. I'll

27:34 never understand this. I'll never be good enough to be a therapist." And all of that leads to their emotional reaction, right? Yeah. Exactly. So reader E might feel discouraged. They might feel a sense of heaviness. So it's a whole chain reaction starting with that core belief and leading to that immediate experience in the situation. Exactly. Okay. So this conceptualization, it starts to be built right from your very first session. Right. It's a continuous process. So, the therapist is taking all the information you're sharing and they're starting to form these educated guesses about what might be going on for you. Yeah. And they're trying to use the simplest explanation that fits the information. And they're also trying to avoid making assumptions that aren't clearly supported by what you've shared. Okay? So, it's very much based on what

28:20 you're telling them. It's not like they're just pulling it out of thin air, right? and they're checking with you regularly to make sure that this understanding feels accurate to you and that it helps make sense of your experience. It's not something that's just imposed upon you. So, it's collaborative. It's ongoing. It can change as new information comes to light. Exactly. It's a working understanding that evolves as the therapy goes on. Right. Now, when you first reach out for CBT, you usually have an initial assessment session. And our source points out that it's more than just getting a label or a diagnosis. While that might be part of it, the assessment session really has a lot of other goals.