Cognitive and behavioural models
The cognitive model, the three levels of thinking, the learning principles behind behaviour therapy, how a CBT formulation is built with the client, and how CBT is done: structured, time-limited, collaborative, with work between sessions.
Quick check
Answer each one in your own words, then open the model answer to compare. Signed in, your answers are kept and marked, and the plan uses them.
1.A 41-year-old accountant works eighty-hour weeks, checks every figure three times and has never had an error, yet is exhausted and certain she is incompetent. Her psychologist proposes to start by reducing the checking. Is that a reasonable first target? Justify your response.
Model answer
It is reasonable, but not as a first step on its own. The checking is a compensatory strategy that protects a core belief of incompetence, and because nothing is ever left unchecked the belief is never tested. Removing the checking before she understands why would leave her anxious and likely to go back to it. The psychologist would first draw the formulation with her, so that she sees the belief, the assumption and the behaviour as one pattern, and then set up reduced checking as a behavioural experiment that tests the prediction that an error will be found and she will be exposed.
2.A 9-year-old girl was knocked over by a large dog. Two months later she is afraid of all dogs, then of the park where it happened, then of leaving the house. Her parents have been keeping her home to settle her and ask whether that is right. What does the psychologist advise them?
Model answer
The two moves are to keep her home until the fear settles, or to plan graded exposure with the parents, and exposure is the right advice. The fear began through classical conditioning and generalised from one dog to all dogs and to the place, and each time she avoids a cue the relief negatively reinforces the avoidance, so the fear cannot extinguish. Keeping her home is well meant, but it is the same avoidance. The psychologist would plan graded exposure with the parents as part of the plan, so that she meets dogs in steps and learns that nothing happens.
3.In the second session a 36-year-old client says, "You're the expert, just tell me what's wrong with me and what to do." The psychologist has a formulation in mind. What should the psychologist do?
Model answer
The two moves are to give the client the formulation as an expert opinion, which is what he has asked for, or to build it with him. Building it with him is right. The formulation is a set of hypotheses, not a finding, so the psychologist drafts it with the client, marks unchecked hypotheses with question marks and asks whether each part fits, which is collaborative empiricism. The psychologist can meet his request by explaining the model and offering the draft as a starting point, and his corrections will improve it.
4.A 38-year-old teacher says: "The principal walked past without saying hello. She's obviously unhappy with my work. If a boss is unhappy with you, you're finished. I've never been good enough at anything." Sort the statements into the three levels, name the distortion in the automatic thought, and say where the work starts.
Model answer
"She's obviously unhappy with my work" is the automatic thought, a quick reading of one situation. It is mind reading, because the teacher believes they know what the principal thinks without considering more likely possibilities, such as a principal in a hurry. "If a boss is unhappy with you, you're finished" is the assumption, a conditional rule that applies across situations, and "I've never been good enough at anything" is the core belief, stated as an absolute, in the helpless group. The work would usually start with the automatic thought, because it is the easiest to catch and to test, and move to the assumption and the belief as the teacher gains the skill.
5.A 29-year-old woman with social anxiety asks to leave out the exposure tasks and "just do the thinking work", because the tasks make her too anxious. Her psychologist is inclined to agree so that she stays in treatment. Is that the best decision?
Model answer
The two moves are to drop the exposure to keep her engaged, or to keep it and work on the rationale. Keeping it is right. In anxiety the treatment works by testing the feared prediction, and avoiding the tasks is the avoidance that maintains the fear, so thought work alone leaves the prediction untested. Clients who do not accept the rationale often do not do the work, so the psychologist goes back to the rationale with her, agrees a smaller first step she can manage, and keeps the exposure in the plan.