COGNITIVE THERAPY TECHNIQUES

Also from Robert L. Leahy Contemporary Cognitive Therapy: Theory, Research, and Practice Edited by Robert L. Leahy

Emotion Regulation in Psychotherapy: A Practitioner’s Guide Robert L. Leahy, Dennis Tirch, and Lisa A. Napolitano

Emotional Schema Therapy Robert L. Leahy

Overcoming Resistance in Cognitive Therapy Robert L. Leahy

Psychological Treatment of Bipolar Disorder Edited by Sheri L. Johnson and Robert L. Leahy

Roadblocks in Cognitive-Behavioral Therapy: Transforming Challenges into Opportunities for Change Edited by Robert L. Leahy

Treatment Plans and Interventions for Bulimia and Binge-Eating Disorder Rene D. Zweig and Robert L. Leahy

Treatment Plans and Interventions for Depression and Anxiety Disorders, Second Edition Robert L. Leahy, Stephen J. F. Holland, and Lata K. McGinn

Cognitive Therapy Techniques A Practitioner’s Guide SECOND EDITION

ROBERT L. LEAHY

THE GUILFORD PRESS New York  London

Copyright © 2017 The Guilford Press A Division of Guilford Publications, Inc. 370 Seventh Avenue, Suite 1200, New York, NY 10001 www.guilford.com All rights reserved Except as noted, no part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the publisher.

This book is printed on acid-free paper. Last digit is print number: 9 8 7 6 5 4 3 2 LIMITED DUPLICATION LICENSE These materials are intended for use only by qualified mental health professionals. The publisher grants to individual purchasers of this book nonassignable permission to reproduce all materials for which permission is specifically granted in a footnote. This license is limited to you, the individual purchaser, for personal use or use with individual clients. This license does not grant the right to reproduce these materials for resale, redistribution, electronic display, or any other purposes (including but not limited to books, pamphlets, articles, video- or audiotapes, blogs, file-sharing sites, Internet or intranet sites, and handouts or slides for lectures, workshops, webinars, or therapy groups, whether or not a fee is charged). Permission to reproduce these materials for these and any other purposes must be obtained in writing from the Permissions Department of Guilford Publications. The author has checked with sources believed to be reliable in his efforts to provide information that is complete and generally in accord with the standards of practice that are accepted at the time of publication. However, in view of the possibility of human error or changes in behavioral, mental health, or medical sciences, neither the author, nor the editors and publisher, nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or the results obtained from the use of such information. Readers are encouraged to confirm the information contained in this book with other sources. Library of Congress Cataloging-in-Publication Data Names: Leahy, Robert L., author. Title: Cognitive therapy techniques : a practitioner’s guide / Robert L.   Leahy. Description: Second edition. | New York : The Guilford Press, [2017] |    Includes bibliographical references and index. Identifiers: LCCN 2016047847 | ISBN 9781462528226 (paperback) Subjects: LCSH: Cognitive therapy. | BISAC: MEDICAL / Psychiatry / General. |    SOCIAL SCIENCE / Social Work. | PSYCHOLOGY / Clinical Psychology. Classification: LCC RC489.C63 L382 2017 | DDC 616.89/1425—dc23 LC record available at https://lccn.loc.gov/2016047847

About the Author

Robert L. Leahy, PhD, is Director of the American Institute for Cognitive Therapy in New York and Clinical Professor of Psychology in the Department of Psychiatry at Weill Cornell Medical College. His research focuses on individual differences in emotion regulation. Dr. Leahy is Associate Editor of the International Journal of Cognitive Therapy and is past president of the Association for Behavioral and Cognitive Therapies, the International Association for Cognitive Psychotherapy, and the Academy of Cognitive Therapy. He is the 2014 recipient of the Aaron T. Beck Award from the Academy of Cognitive Therapy. Dr. Leahy has published numerous books, including Overcoming Resistance in Cognitive Therapy and the coauthored volumes Treatment Plans and Interventions for Bulimia and Binge-Eating Disorder; Treatment Plans and Interventions for Depression and Anxiety Disorders, Second Edition; and Emotion Regulation in Psychotherapy.

v

Preface

T

he first edition of Cognitive Therapy Techniques provided clinicians with a wide range of cognitive-­behavioral techniques that could be used to expand the arsenal of interventions that one could use in clinical practice. When I originally considered what I wanted to cover in that book, I thought of what I would want to know if I were learning cognitive-behavioral therapy (CBT), or what I would want to know if I hadn’t been at this for so many years. Many of us can find ourselves getting “stuck” with—or accustomed to—a few simple techniques. For example, one might just find oneself using techniques such as identifying the automatic thought, examining the costs and benefits of that thought, looking at the evidence, and coming up with another more adaptive thought. That’s fine—up to a point. Or one might think, “I will use some behavioral activation techniques”—and those might work, too. Or mindfulness—that can help. What I have learned, though, is that patients present with a wide range of problems, a wide range of beliefs about change, reasons not to change, and impediments to improvement. So, I guess I turned my own frustration as a clinician into writing a book, one that might be helpful if you want to move beyond your habitual techniques to see if there are some other things you can do. I have been fortunate to have wonderful and creative colleagues at the American Institute for Cognitive Therapy in New York City (www.CognitiveTherapyNYC.com). Rather than churning out “mini-me’s” of me, I have encouraged our staff members to be the best that they can be at being themselves—whether it’s cognitive therapy, behavioral therapy, acceptance and commitment therapy, dialectical behavior therapy, mindfulness, or whatever it is that they do. This experience has been immensely enriching for me because I learn so much from them. So, the current volume reflects a lot of integration of CBT techniques from a wide range of approaches. And, of course, I have learned from the many patients who have trusted me with their care, who have taught me about how things make sense when you are depressed and anxious, and who have sometimes come up with their own ideas of change. I don’t think I am alone as a therapist in having experienced a patient saying something that he or she thinks is helpful, and thinking, “Gee, maybe I should try that in my life.” I have organized this book around certain categories of interventions or techniques, beginning with many of the traditional techniques for identifying and evaluating thoughts and assumptions. Chapters 2–5—“Eliciting Thoughts,” “Evaluating and Testing Thoughts,” “Evaluating Assumptions vii

viii

Preface

and Rules,” and “Examining Information-Processing and Logical Errors”—provide a number of techniques that target the cognitive content of often biased and unhelpful thinking. Chapter 6, “Modifying Decision Making,” examines the typical assumptions and biases—or heuristics—that affect difficulty or problems in making decisions. Decision making has been an interest of mine for years, and so this chapter brings into focus issues such as sunk-cost effects, risk aversion, basing decisions on limited information, overfocus on immediate consequences, and other factors. Many depressed and anxious people have great difficulty in making decisions and often get stuck with situations that they have trouble changing. Chapter 7, “Responding to and Evaluating Intrusive Thoughts,” owes a great debt to the metacognitive model advanced by Adrian Wells, which is one of the truly innovative models of the past decade. Again, intrusive thoughts often lead to an overvaluation of the content of that thought, the tendency to take a thought personally, beliefs that thoughts that are unpleasant or unwanted have to be eliminated, or that these thoughts are out of control. I hope this chapter provides the clinician with some techniques that will innovate change. For those familiar with my writing, it will come as no surprise that I’ve included a chapter on “Modifying Worry and Rumination” (Chapter 8), which provides a great number of techniques that can be combined with the many techniques on coping with intrusive thoughts. This material will be relevant to helping people with worry, rumination, and intrusive thoughts in posttraumatic stress disorder and in other disorders. In Chapter 9, “Putting Things in Perspective,” I provide numerous techniques that can be helpful in supporting patients in reducing their tendency to overreact to events and to assist in accepting the inevitable difficulties in life. Chapter 10, “Identifying and Modifying Schemas,” illustrates a wide range of techniques that one can use to address long-standing schematic issues, often associated with personality disorders or “personality styles.” Clinicians working with patients who experience recurrent problems in relationships, with self-identity, and at work, and who often benefit from longer-term CBT, may find these techniques helpful. Chapter 11, “Emotion Regulation Techniques,” also reflects some of the work by many other clinicians, my colleagues, and me on helping patients utilize coping skills to live with turbulent emotions. Indeed, it may be that some patients will need emotion regulation work before they can even use the other techniques in this book. The last section of the book includes a brief chapter (Chapter 12) with examples of how to address each of the cognitive distortions mentioned earlier. Then I provide three short chapters that address techniques for common problems, such as “need for approval” (Chapter 13), “self-criticism” (Chapter 14), and “anger” (Chapter 15). We could cover many other problems, but I hope these examples will serve as a guide to how clinicians can actually use a wide range of techniques for other common and not-so-common problems. My hope is that clinicians will be able to integrate additional techniques and strategies to overcome impasses that inevitably occur, and provide patients with new skills to use in handling the difficulties that they face. No technique is a panacea, and no model is perfect. Given the world of limitations in which we live, having additional coping skills can make the difference between getting stuck and making the change that really matters. It’s part of the flexibility that we should all embrace.

Acknowledgments

O

ne of the pleasures in writing a book is to acknowledge the influence and support that I have received over the years. First, I want to thank Jim Nageotte, who has been a wonderful editor since working on my first book with The Guilford Press. Also, Jane Keislar and Jeannie Tang from Guilford and copyeditor Margaret Ryan have been remarkably conscientious in making much of this into a reality. There have been so many people whose work has influenced me, beginning with Aaron T. Beck, the founder of cognitive therapy. I also wish to acknowledge the important influence of the following people: Jill Abramson, Lauren Alloy, Arnoud Arntz, David Barlow, Judith Beck, David Burns, David A. Clark, David M. Clark, Frank Dattilio, Keith Dobson, Michel Dugas, Edna Foa, Paul Gilbert, Allison Harvey, Steve Hayes, Stefan Hofmann, Emily Holmes, Sheri Johnson, Marsha M. Linehan, Doug Mennin, Cory Newman, Christine Purdon, Stanley J. Rachman, John Riskind, Paul ­Salkovskis, Debbie Sookman, John Teasdale, Dennis Tirch, Adrian Wells, Mark Williams, ­Jeffrey Young, and Zindel V. Segal. I am also indebted to my colleagues at the American Institute for Cognitive Therapy, who over these many years have probably heard some version of almost everything that I have published. In particular, I wish to thank Melissa Horowitz, Laura Oliff, Susan Paula, Mia Sage, Scott Woodruff, Maren Westphal, and Peggilee Wupperman. Of special note, I wish to thank my editorial assistant Sindhu Shivaji, who has worked tirelessly, beyond the call of duty, in every phase of the editorial and research process. I would also like to thank my friend and colleague Philip Tata, from the British Association for Behavioural and Cognitive Psychotherapies, who has been a wonderful guide and support to me for many years. And, of course, where would I be without my lovely, thoughtful, wise wife, Helen, who continues to provide the humor and support that have made all of these endeavors possible? It is to her that this book is dedicated.

ix

Contents



List of Forms

xiii

PART I.  BEGINNING COGNITIVE THERAPY Chapter 1 Introduction

3

PART II.  TECHNIQUES Chapter 2 Eliciting Thoughts

15

Chapter 3 Evaluating and Testing Thoughts

50

Chapter 4 Evaluating Assumptions and Rules

96

Chapter 5 Examining Information‑Processing and Logical Errors

146

Chapter 6 Modifying Decision Making

182

Chapter 7 Responding to and Evaluating Intrusive Thoughts

220

Chapter 8 Modifying Worry and Rumination

249

Chapter 9 Putting Things in Perspective

321

Chapter 10 Identifying and Modifying Schemas

361

Chapter 11 Emotion Regulation Techniques

413

xi

Contents

xii

PART III.  SPECIFIC APPLICATIONS Chapter 12 Examining and Challenging Cognitive Distortions

455

Chapter 13 Modifying Need for Approval

473

Chapter 14 Challenging Self‑Criticism

478

Chapter 15 Managing Anger

488

Chapter 16 Concluding Comments

497



References 501

Index

Purchasers of this book can download and print the forms at www.guilford.com/leahy3-forms for personal use or use with individual clients.

509

List of Forms

FORM 2.1.

Distinguishing Events, Thoughts, and Feelings

39

FORM 2.2.

How Thoughts Create Feelings

40

FORM 2.3.

The A-B-C Technique

41

FORM 2.4.

Other Possible Facts

42

FORM 2.5.

Rating Emotions and Beliefs

43

FORM 2.6.

Tracking Degree of Belief in a Thought

44

FORM 2.7.

Checklist of Cognitive Distortions

45

FORM 2.8.

Categorizing Your Thought Distortions

46

FORM 2.9.

Using the Vertical Descent (Why Would It Bother Me If My Thought Were True?)

47

FORM 2.10. Looking at Probabilities in a Sequence

48

FORM 2.11. Guessing at the Negative Thought

49

FORM 3.1.

Defining the Terms

81

FORM 3.2.

Making Definitions Clear

82

FORM 3.3.

Cost–Benefit Analysis of a Thought

83

FORM 3.4.

Examining the Validity of Costs and Benefits, Short-Term and Long-Term

84

FORM 3.5.

Examining the Evidence

85

FORM 3.6.

Examining the Quality of the Evidence

86

FORM 3.7.

Playing the Role of Your Own Defense Attorney

87

FORM 3.8.

Are My Challenges Relevant to My Negative Thoughts?

89

xiii

List of Forms

xiv

FORM 3.9.

Role Playing Both Sides of the Thought

90

FORM 3.10. Evaluating Negative Labels

92

FORM 3.11. Looking for Variations

94

FORM 3.12. Changing Negative Thoughts by Changing Behavior

95

FORM 4.1.

Monitoring Your Assumptions, Rules, and Standards

127

FORM 4.2.

Examining and Challenging “Should” Statements

128

FORM 4.3.

Identifying Conditional Beliefs

129

FORM 4.4.

Evaluating Second-Level Assumptions

130

FORM 4.5.

Values Clarification

131

FORM 4.6.

Perfectionism Inventory

132

FORM 4.7A. Costs and Benefits of Progress and Perfection

136

FORM 4.7B. Making Progress Rather Than Trying for Perfection

137

FORM 4.8.

Learning from Lapses

138

FORM 4.9.

Case Conceptualization Diagram

139

FORM 4.10. Examining the Implications of Perfectionism

140

FORM 4.11. Turning Work into Play: Changing Criticism and Disappointment

141

FORM 4.12. Changing Old Rules/Assumptions into New Rules/Assumptions

142

FORM 4.13. My New Bill of Rights

145

FORM 5.1.

Examining Confirmation Bias

171

FORM 5.2.

Using All the Information

172

FORM 5.3.

Estimates of the Likelihood of Events

173

FORM 5.4.

Examining Logical Errors

174

FORM 5.5.

Seeing Patterns That May Not Be There

175

FORM 5.6.

Challenging False Dichotomies

176

FORM 5.7.

Reducing Thoughts to Absurdity

177

FORM 5.8.

Mood Induction and Alternative Thoughts

178

FORM 5.9.

Examining the Recency Effect

179

into Curiosity

FORM 5.10. Fallacies in Arguments: Analyzing Negative Beliefs

180

FORM 6.1.

Focusing on Short-Term Goals

208

FORM 6.2.

Focusing on Longer-Term Goals

209

FORM 6.3.

Committing to the Future by Deciding Now

210

FORM 6.4.

Examining Sunk Costs

211

List of Forms xv



FORM 6.5.

Mood and Decision Making

214

FORM 6.6.

Viewing Losses and Gains as a Focus in Making Decisions

215

FORM 6.7.

Regret Avoidance

216

FORM 6.8.

Decisions by Current and Future Selves

217

FORM 6.9.

Past, Current, and Future Rewarding Activities

218

FORM 6.10. Risk versus Risk Choices

219

FORM 7.1.

Detached Mindfulness

238

FORM 7.2.

Imagining the Thought as Something Else: Don’t Take the Call

239

FORM 7.3.

Thought Balloon

240

FORM 7.4.

Thoughts versus Reality

241

FORM 7.5.

Are These Thoughts Really Relevant?

242

FORM 7.6.

The Thought Visitor

243

FORM 7.7.

The Thought Clown

246

FORM 7.8.

Problematic Responses to an Unwanted Thought

247

FORM 7.9.

The Boredom Technique

248

FORM 8.1.

Self-Monitoring of Worries

296

FORM 8.2.

Costs–Benefits of Worry

297

FORM 8.3.

Turning Worries into Predictions

298

FORM 8.4.

Making Thoughts and Predictions Testable

299

FORM 8.5.

Testing Negative Predictions

300

FORM 8.6.

Examining Past Negative Predictions

301

FORM 8.7.

Possible Outcomes

302

FORM 8.8.

Stories about Outcomes

303

FORM 8.9.

Examples of Imperfect Solutions

304

FORM 8.10. Reviewing How I Handled Past Negative Events

305

FORM 8.11. Why I Don’t Learn from Past Predictions

306

FORM 8.12. Point–Counterpoint

307

FORM 8.13. Productive and Unproductive Worries

308

FORM 8.14. Keeping Track of Worries for Worry Time

309

FORM 8.15. Making Negative Predictions Come True: Self-Fulfilling Prophecies

311

FORM 8.16. Flooding Yourself with Uncertainty

312

FORM 8.17. Take Yourself Out of It/Disappear

313

FORM 8.18. Grain of Sand

314

PSYCHOLOGY

Cognitive Therapy Techniques A Practitioner’s Guide

SECOND EDITION

ROBERT L. LEAHY “In this second edition of his classic work, Leahy provides a plethora of invaluable techniques for creating therapeutic change in cognitive therapy. Trainees and experienced therapists will find this volume an indispensable repository of strategies that work.” —Adrian Wells, PhD, School of Psychological Sciences, University of Manchester, United Kingdom “The second edition not only provides expert guidance on traditional cognitive therapy, but also includes newer elements such as behavioral activation, acceptance, and mindfulness. Leahy blends scientific evidence with extensive clinical experience to create a compelling teaching experience for the reader.” —David F. Tolin, PhD, ABPP, Director, Anxiety Disorders Center, The Institute of Living–Hartford Hospital “Leahy—one of our most astute and knowledgeable cognitive therapists—synthesizes many years of clinical wisdom with a sophisticated understanding of current research. This book serves as a wonderful resource for novice cognitive-behavioral clinicians, but also offers much to skilled practitioners, who can find ways to augment their favorite strategies and techniques with the latest clinical advances.” —John H. Riskind, PhD, Department of Psychology, George Mason University; editor, International Journal of Cognitive Therapy “Substantially updated, this is the best available compendium of techniques spanning the broad range of current cognitive and behavioral therapies….Featuring clear, jargon-free language, clinical tips, illustrative examples, and practical forms, the book presents state-of-the-art tools applicable to treating a wide range of clients and disorders.”—Drew Erhardt, PhD, Graduate School of Education and Psychology, Pepperdine University @

Sign up for exclusive offers! www.guilford.com/e-alerts

The Guilford Press 370 Seventh Avenue New York, NY 10001 www.guilford.com

T

his indispensable book has given many tens of thousands of practitioners a wealth of evidence-based tools for maximizing the power of cognitive therapy and tailoring it to individual clients. Leading authority Robert L. Leahy describes ways to help clients identify and modify problematic thoughts, core beliefs, and patterns of worry, self-criticism, and approval-seeking; evaluate personal schemas; cope with painful emotions; and take action to achieve their goals. Each technique includes vivid case examples and sample dialogues. Featuring 124 reproducible forms, the book has a large-size format for easy photocopying; purchasers also get access to a Web page where they can download and print the reproducible materials. New to This Edition: • Numerous additional techniques and reproducible tools, including 48 new or revised forms. • Chapters on decision-making problems, intrusive thoughts, and anger management issues. • Incorporates the latest theory and research as well as cutting-edge techniques drawn from acceptance and commitment therapy, behavioral activation, dialectical behavior therapy, emotional schema therapy, and the metacognitive model. • Significantly revised chapters on emotion regulation and worries. • Filled-out examples for many of the forms. Robert L. Leahy, PhD, is Director of the American Institute for Cognitive Therapy in New York and Clinical Professor of Psychology in the Department of Psychiatry at Weill Cornell Medical College. Reproducible materials also available online for purchasers. Cover design by Paul Gordon; image by Getty ISBN 978-1-4625-2822-6

9 781462 528226 >