灘
CognitiveTherapy
inanutshell
MichaelNeenanandWindyDryden
③SAGE
Angeles London lNewDelhl
3ingapo｢eWashingtonDC
◎MichaelNeenanandWmdyDryden2006
Firstpublished2006
Reprinted2009
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Contents
Preface
1
Anoverviewofcognitivetherapy
2Assessment
3
Elicitingandexaminingnegative
automaticthoughts
4Homework
5
Uncoveringandexaminingunderlying
assumptions,rulesandcorebeliefs
6Maintaininggainsfromtherapy
V］
1
18
34
59
75
97
References
104
Index
108
Preface
ThereisavastliteratureoncognitivetherapyICTlasbefitsthe
'singlemost importantandbestvalidatedpsYchotherapeutic
approach・ It isthepsychological treatmentofchoicefora
widerangeofpsychologicalproblems' (Salkovskis,1996:xiii;
HollonandBeck, 20041.However, anewcomertoCTcould
feeldauntedbyhavingsomuchonofferbutnotknowing
wheretostarttogainaninitialunderstandingofthisapproch
(plungingstraight intodisorder‑specific treatmentmanuals
couldbeconfusingasthesearewrittenfore"eriencedCT
practitioners,notbeginnersITherefore,ouraiminthisbookis
topresentthekeyelementsofcognitivetherapy/boththeory
andpractice, inasfewwordsaspossible‑aprimeronCTIWe
haveusedthecaseexampleofaclientwithsocialphobiain
ordertodemonstrateCTinaction.Wehaveendeavouredto
makeourpresentationofCTclearandourprosestyleeasyto
readasbefitsthebooksintheCoz"zselliJgi〃αlV"s/zeIIseries.
蕊
AnOverviewof
；Ⅷ…
Introduction
Threepeopleworkingforthesamecompanyatthesame
levelandsalaryareallmaderedundantatthesametime.
Thefirstpersonisangrybecauseshebelievessheshould
havebeenpromoted,notsacked; thesecondpersonisanx‑
iousbecausehethinksaboutthefinancialdifficultiesthat
lieahead; thethirdpersonishopefulbecauseshethinks
aboutthegoodopportunitiesthatredundancymayleadto.
Thesethreedifferentemotionalreactionstothesameevent
underscoreakeyideaincognitivetherapyICT):namely,
thatourreactionstoeventsarepowerfullyinfluencedbythe
wayweviewtheseevents.By'tappingtheinternalcommu‑
nications'IBeck{ 19761'youcandiscoverthethOughtsand
beliefsthatlargelydeterminetheclient'semotionalresponses
toevents･Burns (1980)summarizesthecognitivemodelaS
ﾉvoufeelthewavvouthinkI.
ニ
ニユ
Someclients landtherapists)mightsaythateventsdo
directlycauseouremotionalreactionsand' forexample,
pointtoeveryonebeinganxiousiftheywereinaburning
building.Whileeveryonemaywellbeanxious,somepeople
mightbeinawildpanic, creatingadditionaldangersfor
themselvesandothers; somearefrozeninterror;while
othersarestrugglingtostayincontrolofthemselvesinorder
tofindawayout・Whenoutside, somewillcalmdownand
recovermorequicklythanothersfromtheordeal,while
oneortwoindividualsmaygoontodevelopfull-blown
post-traumaticstressdisorderIPTSD).Allhavee"erienced
thesameeventbutonlybyexaminingeachperson'sviewpointcanyoutrulyunderstandwhytheyreactedinthe
waythattheydidland, insomecases, continuetosuffer
fromtheirexperiencesl.
三①どの曽三砲昌蚤旦廻①垂ト①こ﹄声司︒︒
CTteachesclientsthatthereisalwaysmorethanoneway
ofseeingeventsand, therefore, theirviewpointislargelya
matterofchoiceIButlerandHope,19961.'Helpingclients
todevelopandmaintainmorehelpfulviewpointsintackling
theirproblemsisthefocusoftherapy.
CTwasdevelopedbyAaronTBeckattheUniversityof
Pennsylvaniaintheearlyl960s.2Beck'sapproachinitially
focusedonresearchinto!andthetreatmentof,depression
IBecketal.,1979).Sincethen,CThasbeenappliedto
anever-increasingnumberofclinicalproblems suchas
anxietyandphobiasIBecketal.,1985),substanceabuse
IBecketal.,19931,schizophreniaIKingdonandThrkington
20041,obsessive-compulsivedisorderISalkovskis,19991,posttraumaticstressdisorder IEhlersandClark,2000),health
anxiety ('IhylorandAsmundson, 20041, bipolardisorder
IBascoandRush,20051andtoworkwithcouples IDattilio
andPadesky, 1990), psychiatricinpatients (Wrighteta1.,
1993),peoplewithpersonalitydisorders IDavidson,20001,
childrenandyoungpeopleIStallard,2002)andolderpeople
(Laidlaweta1.,20031.
Theory
Information-ProcessingModel
CTisbasedonaninformation-processingmodel 'which
positsthatduringpsYchologicaldistressaperson'sthinking
2
becomesmorerigidanddistorted,judgementsbecome
overgeneralizedandabsolute, and theperson's basic
beliefsabouttheself,[otherslandtheworldbecomefixed'
|Weishaar,1996: 1881.Inotherwords,whenwebecome
emotionallydistressed,ournormalinformation-processing
abilitiestendtobecomefaultybecauseweintroduceaconsistentlynegativebiasintoourthinking.Forexample,a
personwhomakeshimselfangryovernotbeinginvitedto
apartyldenounceshisfriendsas｣bastardsandbackstabbers!
anddeclareshewiⅡ′getthembackforhumiliatingme' fails
toconsiderotherreasonsfornotbeinginvitediforexample,
hebecomesaggressivewhenhehashadtoomuchtodrink).
Commoninformation‑processingerrorsordistortionsin
emotionaldistressinclude:
。All‑or‑nothmgthinkmg:
Situationsareviewedineither/
・Mmd‑reading: Ybubelieveyoucandiscernthethoughts
ofotherswithoutanyaccompanyingevidencel'Shedoesn't
havetotellme‑Iknowshethinksl'manidiot').
o
Labelling: Insteadoflabellingonlythebehaviour,you
attachthelabeltoyourselfl'Ifailedtogetthejob, sothat
makesmeafailure' ).
･ Jumpmgtoconclusions: Drawingconclusionsonthe
basisofinadequatedata('Mygirlfrienddidn'tphonewhen
shewassupposedto' soshemustbegoingoffme'l.
・E1notionalreasonmg: Assumingthatyourfeelingsare
facts{'Ifeelaphoneyfornotbeingabletoanswertheques‑
tion,solmustbeone'1.
'Ibachingclientshowtoidentifythesecognitiveerrors
facilitatesthereturnofinformation-processingthatismore
nexible,accurate!evidence-basedandrelative(non-absolute)
initsappraisalofevents.3
3
Ｏ更の﹃ミの弓
orterms (forexample, 'Eitheryou'reasuccessorfailurein
life.Thereisnoin‑between') ̲
HierarchicalOrganizationof
Thinking
ThreecognitivelevelsareusuallyexaminedinCT:
一両△２コ三町ミ蚤旦餌句塁ト①ミ蓬匡画○○
1 AutomaticThoughts
Thesearethoughtsthatcomerapidlyi automaticallyand
involuntarilywhenapersonisinanegativeframeofmind
IGilbertl2000alcallsthem'pop-upthoughts'l.Automatic
thoughtscanbetriggeredbyexternaleventsIlateforameeting: 'They'llthinkbadlyofme.Myopinionwon'tcount.
I'lllosetheirrespect'land/orinternalevents(poundingheart:
'1'mhavingaheartattack. Iimgoingtodie・OhGod!' ).
Automaticthoughtsaresituation‑specificandtheeasiest
cognitionstogainaccesstobyaskingthe'cardinalquestion
ofcognitive therapy:Whatwasjustgoingthroughmy
mind?'IBeck,1995:10).Automaticthoughtscanalsooccur
asimages,suchasapersonseeinghimself'dyingofembar‑
rassment' ifhemakesa/tmxpqswhenheisthebestman
athisfriendiswedding.
2 UnderlyingAssumptions/Rules
Thesearetheoftenunarticulatedassumptionswhichguide
oureverydaybehaviour,setourstandardsandestablishour
rules.Apositiveassumptionmightbe'Iflworkhard, then
Iwillbeasuccessinlife' andanaccompanyingnegative
assumptionlthereversesideofthepositiveone)mightbe
'Iflslackeninanywaylthenlwillbeafailure'.Underlying
assumptionsareoftenidentifiedbytheir 'if…then' or
!unless…then' constructionlforexample, 'Unless l'm
respectedbyothers,Icanneverhaveself-respect').Rules
areoftene"ressedin'should' and'must' statements ('I
mustnevershowanvweaknesses'; 'Ishouldalwavsbethere
ユ
ニ
formyfriendswhentheyneedme' ).Aslongastheterms
oftheserules, standardsandpositiveassumptionsaremet,
individualsremainrelativelystableandproductiVeand
4
therebyavoidactivatingthe 'bottomline'! ornegative
corebeliefs IFennell, 19971.Underlyingassumptionsare
cross-situational.
3
CoreBeliefs(Schemas)
Thesearethefundamentalbeliefsaboutourselves,others
andtheworldthathelpustomakesenseofourlifeexperiences.Weusuallyhavebothpositive ('1'mgreat') and
negativel'1#museless'lcorebeliefs.Corebeliefsareusually
formedthroughearlylearningexperiencesandbecome
instrumentalinshapingouroutlook. Inemotionaldisturbance, absoluteandglobalnegativecorebeliefsareactivatedandthenprocessinformationinabiasedwaythat
maintainsthecorebeliefanddiscreditsordisconfirmsanV
contradictoryevidence.
Oncethedisturbancehaspassedorameliorated,negative
stateandamorepositiveoutlookisre-establishedIclients
withpersonalitydisordersmayhavetheirnegativecore
beliefsactivatedmostofthetime, seeDavidson, 20001.
Theterms 'corebeliefs'and'schemas'aresometimesseen
assynonymous.4Beck(1995) suggeststhatnegativecore
beliefscanbeslottedintotwobroadcategoriesofhelplessness (｣I'mweak!landunloveability('1'mundesirable!1 .
Howdothesethreecognitivelevelsinteract？Forexample，
anegativecorebelief('1'munattractive') isactivatedwhena
client'spositiveassumptionl｣IfamanisintereStedinme,
thenthatprovesl!mattractive'lisunderminedbyrejection
I'He'snotinterestedinme,sothatproveslmustbeunat‑
tractive'1.Hermind is floodedwithnegativeautomatic
thoughts lNAEl suchas 'WhVdidhedumpme？Ican't
copewithouthim.IhatebeingonmyownHe'sProbably
laughingatmenowwithhisnewwoman'.Theusualtreat‑
mentstrategyinCTistofocusontacklingNAIbtoeffect
symptom‑reliefbeforemovingontomodifyingunderlying
assumptionsandcorebeliefstoachievelonger‑termchange.
5
○言⑩﹃ミのミ
corebeliefsbecomedeactivatedorreturntotheirlatent
Reciprocal lnteractionof
Thoughts,Feelings,Behaviours,
PhysiologyandEnvironment
■
一可︽耐営︾之殉ミ語Ｑ妃﹄①兵トの量逹屋ｑｏＱ
CTdoesnotfocusexclusivelyonexaminingthoughtsand
behefs.GreenbergerandPadeskyll995) suggestthereare
fiveaspectstoaperson'slifeexperience: thoughts,moods,
behaviours#physicalreactions, andenvironment lpastand
present).Fbrexample,apersonwholosesherjoblenvironmentI seesherselfasafailure lthought), feelsdepressed
|mood),withdrawsfromsocialactivities lbehaviourl and
complainsoflackofenergyandtirednessIphysicalreactionl.
Anychangeinoneoftheseaspectsiscapableofinnuencing
theothersinaninteractivecYcle, forexample, areturnto
socialactivitiesinitiateschangesintheotheraspects.
InCTItheusual'wayin' tostartthechangeprocessisby
examiningandmodifyingclients' negativethoughts (Are
thereotherwaysofviewingjoblossinsteadofseeingit
onlyintermsofself-condemnation?')asthishasapositive
influenceonmood,behaviour,physicalreactionsandhow
clientsrespondtoenvironmentalstressors.Usingthepreviousexample, theclientnowviewsjoblossaspartofthe
employment/unemploymentcycleratherthanasanevaluationofherself-worth.Thisnewviewofthesituationlifts
theclient'smood: shebecomesmuchmoreenergetic,
returnstosocialactivitiesandstartsupdatingherCVin
preparationformorejobapplications.
CognitiveContent-Specificity
Hypothesis(Beck,1976)
Thisproposes thateachemotionaldisorderhasitsown
typicalcognitivecontentortheme: devaluationorlossin
depression; dangeror threat inanxiety; situationallyspecificdangersinphobia;uniustifiedintrusioninparanoia;
transgressioninanger.Thishypothesiswassubstantiated
byempiricalresearchinthel980sIWeisharr,1996).This
6
cognitivecontentislinkedtoBeck's I1976I conceptofthe
!personaldomain' lanythinganindividualfindsimportant
inhiS/herlife). Someexamplesmayhelptoexplainthis
relationship:
・Anindividualwhoseesherselfasasuccessfulbusiness‑
womanbecomesdepressedwhenhercompanyfailsasshe
concludesthat 'Mylifeismywork,andwithoutmywork,
IImnothing'､
・Anindividualwhoprideshimselfonhissexualprowess
becomes intenselyanxiouswhenheexperienceserectile
failurewithhiscurrentgirlfriend.
･Anindividualwhoenjoyspeaceandquiet inher life
becomesenragedwhenhernextdoorneighbourplayshis
muSictooloudly.
hassufferedsubtraction, thesecondperson's isendan‑
geredandthethirdperson'sisbeingimpingedupon.
CognitiveVulnerability
Thisreferstothoseidiosyncraticfactorsthatpredisposean
individualtoexperiencepsychologicaldistress.Whatmay
precipitatedistressinoneperson(forexample, failingto
getjobpromotion)doesnotinducedistressinanother lhe
shrugsoffnotgainingpromotion).Beckll9871hypothesizedtwobroadpersonalitytypeswhowouldbeproneto
experiencingdepressionafteraperceivedsignificantlosssociotropyandautonomy:
Theautonomousindividualgetshissatisfactionfrominde-
pendence, freedomandpersonal achievement!whilethe
7
︒ご里く耐ミ
Howanindividualrespondsemotionallytoevents'depends
onwhetherheperceiveseventsasaddingto! subtracting
from' endangering,orimpinginguponhisdomain! IBeck,
1976:561 . Intheaboveexamples, thefirstperson'sdomain
sociotropicindividualisdependentonsocialgratifications,
suchasaffection/ companyandapproval.(Blackburnand
Davidson: 1995:29)
Depressionmaybetriggeredinautonomousindividualsif
theyareblockedfromattainingimportantgoals,whereas
depressionmayoccur insociotropic individuals ifthey
becomesociallVisolated.
聖
ContinuumofEmotionalReactions
CTsuggestsacontinuitybetween'normal' emotionaland
behaviouralreactionstolifeeventsandexcessiveemotional
一志塁の冒之町昌謡Ｑ何句垂ト①亀凸這句︒︒
andbehaviouralreactionsfoundinpsYchopathologyldistur‑
bancesinthoughts, feelingsandbehavioursl.AsWeishaar
andBeckexplain:
Thecognitivecontentofsyndromesle.g.anxietydisorders,
depression)havethesamethemeldangerorloss, respectively)asfoundin'normal'experience,butcognitivedistortionsaremoreextremeand,consequentlyIsoareaffect
andbehavior・ (1986:651
AIso, physiological reactions Isuchas increasedheart
rate)wouldbesimilar iftheperceivedthreatwaspsy‑
chosocial lmakingmistakesinfrontofothers)orphysical
￨beingthreatenedinthestreetl .Explainingtoclientsthis
continuumofcognitive‑emotive‑behavioural‑physiological
responsestolifeeventscanhelpthemtodestigmatizepsy‑
chologicaldistressandtherebynormalize it (Weishaar,
19931 ．
MaintenanceofEmotionalDisorders
CTfocusesprimarilyonthefactorsthatmaintainemo‑
tionaldisorders rather thanhowtheseproblemswere
acquired{howtotackleaproblemratherthanwhyitcame
8
intobeingl.Whileadevelopmentalhistoryoftheproblem
isnotneglected,
variables that causedcurrent, psychologicalproblems
cannotbechanged,becausetheyoccurredintheunalterablepast.However｢ thepresentvariablesthatmaintain
theseproblemscanbemodified,andthisis,ofcourse,the
goalofpsychotherapy. (Bond, 1998:84)
Forexample, aclientwithpanicdisordermayaskunan‑
swerablequestionsI'Whydidlgetpanicattacks?Whydid
nooneelseinmyfamilygetthem?' landbecomefrustrated
thatnosatisfyingorcompleteanswersareforthcomingfrom
thetherapist｢whereasencouraginghimtoundertakeatreat‑
mentprogrammeofprovenefficacYIClark, 19891wmreplace
tionaldisordersasindividualsactinwaysthatsupportor
reinforcetheirdysfunctionalbeliefs.Withpanicdisorder,
clientsengageinsafety‑seekingbehaviourswhichprevent
thefearedcatastrophefromoccurring (Salkovskis,19911.
Forexample,oneclientholdsontosomethingorsitswhen
shefeelsdizzyandtherebypreventsherselffromfainting;
anotherclientavoidsexercisesoasnottostrainhisheart
andtriggeraheartattack・Encouragingclientstodroptheir
safetybehaviourshelpsthemtogaugemoreaccuratelythe
trueextentoftheriskstheyface.
Practice
CollaborativeEmpiricism
(Becketal.,1979)
Thisreferstothetherapistandclientworkingtogetherto
tacklethelatter'sproblems;clientsareactivelyengagedin
9
○くの﹃ミ①ミ
profitlessspeculationwithobservableimprovement.
Behaviourplaysanimportantroleinmaintainingemo‑
theproblem-solvingprocessIthisrelationshipisundexpinned
bywarmth, trust, genuinenessandaccurateempathyl.
jEmpiricism' focusesonreality-testingclients' thoughts,
assumptionsandbeliefs.Clients' cognitionsareviewedas
hypothesesratherthanasfacts;forexample, aclientwho
believes 'I'1lneverbehappyagainノ followingtheendofa
relationshipis,fromtheCTviewpoint,makingableakpre‑
dictionbasedonhercurrentstateofmindratherthanstat‑
inganimmutableandaccurateviewofherfuture.
Evidencecollectedfromreality‑testingltheclientfinds
happinessslowlyreturningthroughrenewedsocializing) is
evaluatedtodetermineifitconfirmsorcontradictsclients'
菫２耐萱︾三町ミ当Ｑ駒句兵器①葺轌種一句︒︒
hypothesesand'bythismeans/ clientsareencouragedto
viewtheirthoughtsaspersonalconstructs [assumptions]
ofrealityandtobundtheirskillsinevaluatingtheirvalidity'
(NelsonJones,1995:3121.Throughcollaborativeempiricism,
clientslearntobecomepersonalscientists Iorhypothesis
testersl.
Problem-FocusedandGoal-Oriented
Clientsareencouragedtolisttheirproblemsinthefirst
sessionandestablishagoalforeachone lproblemsare
prioritized, thoughthemosttroublingonemaynotalways
betackledfirst).Thisteachesclientsthatanearlyproblemsolvingfocusissoughtratherthanthemusingupvaluable
therapytimewithramblingorverylongaccountsoftheir
currentdifficulties・Goalsarestatedinobservableand
concretetermssoprogresscanbemeasuredratherthan
assumed.Forexample, aclientwhoavoidsaskingwomen
outforfearofbeingrejectedandthenrejectinghimself
￨ 1I'munlikeable'),agreestoaskforthreedateseachweek
inordertoprovetohimselfthathedoesnothavetorejeCt
himSelfbecausesomeothersdo.Goalscanchangeoverthe
courseoftherapyasmoreinformationiselicited,problems
change,ornewonesemerge.
10
GuidedDiscoveryandSocratic
Questioning
Inguideddiscovery｢ thetherapist: actsasaguidetohelp
clientsuncover,examineandreality‑testtheirmaladaptive
thoughtsandbeliefs; aids thedevelopmentofadaptive
andbalancedresponsestothesecognitions;andassistsin
thedevelopmentofbetterproblem‑solvingdecisions.This
processisfacilitatedbySocraticquestioningwhich'opens
up' clients' closedandproblem‑perpetuatingpatternsof
thinkingconnectedto theirproblems, andencourages
newthinkingabouttheseproblems.Becketal・ statethat
Socraticquestions 'shouldbephrasedinsuchawaythat
theystimulatethoughtandincreaseawareness,ratherthan
requiringacorrectanswer' (1993:103).Forexample,'What
doyouthinkholdsyoubackfromseekingpromotion?'
thatholdsyouback?'OtherexamplesofSocraticquestion‑
ingmightincludelwithananxiousclient) :
'Whatthoughtsorimagesweregoingthroughyourmindto
makeyoufeelintenselyanxiousaboutgivingthatpresentation
toyourcolleagues?'
IWhatwouldbesoterribleaboutnotknowingtheanswertoa
question?'
IWhatwouldthatmeanaboutyouifyoucouldn'tanswerit?'
'Howwouldyouliketocopeifyoucouldn'tansvveraquestion, insteadof"goingtopieces"?!
'Howwouldyouliketoseeyourselfifyoustoppedcalling
yourself"incompetent"?'
GuideddiscoverythroughSocraticquestioningisnotabout
arguingwithclients｢eXposingtheir'poor' thinkingortellmg
themwhattothink‑theyareunlikelytobeconvincedifthe
therapistjusthandSthem'anexplanationfortheirworries.
HelpingclientstothinkthingsthroughforthemselvesassiSts
11
○く①﹃ミ⑩三
ratherthan'Isn!t itthefearofadditionalresponsibilities
andacceleratestheirprogresstowardsbecomingtheirown
therapist.5
CaseConceptualization
Thisreferstounderstandingclients'problemswithinthe
cognitivemodelofemotionaldisorders｡Theprimaryfocusis
onthecognitive‑behaviouralfactorsthatmaintainclients'
currentemotionaldifficultiesandtheunderlyingbeliefsand
assumptions,personalityvulnerabilities,pasttraumasand
lifeexperiencesthatpredisposethemtoe"eriencetheir
problems.Pastandpresentinteracttoproduceanidiosyn‑
■
菫①仁２．之呵ミ語旦町﹄①全ト①ミ廷臣句︒︒
craticclinicalpictureofthepresentingproblem.Fromthis
conceptualization,atreatmentplanisconstructedtoguide
therapybAcaseconceptualizationisviewedastentativeasit
issubjecttorevisionandrefinementasfurtherinforma‑
tionabouttheclient'sproblemsisrevealedlaninitialcase
conceptualizationcantakeseveral sessions tocomplete
dependingonthecomplexityofthepresentingprobleml.
Caseconceptualizationisalsoknownascaseformulation.
Fornovicetherapistsノ confusioncanariseoverthedif‑
ferencesbetweendiagnosisandcaseconceptualization:the
formerattachesalabeltotheclientafteraninitial inter‑
view(suchasobsessivecompulsivedisorderlwhilethe
latter seeks tounderstandtheonset, developmentand
maintenanceofthedisorderwithinanidiosyncraticframe‑
workiadiagnosisislesslikelytohelpthetherapistunder‑
standtheclient'sinternalrealitV.
ユ
Openness
AsCTpracticeisbasedoncollaboration, therapyisopen
andexplicitabout 'whatisgoingon', sotheCTmodel is
explainedtoclientsandtheirpermissionissoughttoapplyit
totheirproblems;thecaseconceptualizationissharedwith
themandtherapists'hypothesesareopentoconfirmation,
12
modificationorrejectionbasedonincominginformation
lthetherapistshouldnotseekinformationthatonlysupportsherhypotheses)・Therapists'mistakesareadmitted
andclientsareencouragedtocomeupwithsolutionswhen
therapybecomesstalled.CTrejectsany'"private"therapist
modelswithinthecognitivetherapyparadigm,asthiswould
sabotagethecollaborativestance'IBlackburnandTWaddle,
1996:91．
HereandNowFocus
Asdiscussedinthetheorysection,CTlargelyfocuseson
findingspecificsolutionstocurrentproblems.Exploration
ofthepastonlyoccurswhen
thepatientexpressesastrongpredilectiontodoso;when
howtheseideasaffectthepatienttoday. (Beck, 1995:7)
Continuallylookingbackwardscanconvincetheclient
thatthesolutiontoherproblemsliesinunderstandingher
pastinsteadofchangingherpresentcircumstancessothat
tomorrowcanbebetterthantoday.6
AgendaSetting
This isabusiness-likeapproachtotherapybut it isnot
carriedoutinanimpersonalwayBClientandtherapistagree
ineachsessionwhichtopicsaretobeputontheagenda,
andthisdevicekeepsbothparticipantsontrackthereby
preventingorminimizingdrift.Agendasettingmilitates
againsttheclientplayingapassiveroleintherapyand
makesefficientuseoftherapytime.TheusualitemsPlaced
13
■
nocognitive'behavioral,andemotionalchange;orwhen
thetherapistjudgesthatitisimportanttounderstandhow
andwhenimportantdysfunctional ideasoriginatedand
︒ご①﹃ミのミ
workdirectedtowardcurrentproblemsproduceslittleor
ontheagendaare:undertakingamoodcheckincludinga
reviewoftheclient!sinventorvscoressuchasthoseof
theBeckDepressionlnventoryIBecketa1., 19961;eliciting
feedbackfromtheprevioussession; reviewinghomework;
agreeingontopicsforthecurrentsession;negotiatingnew
homework;andaskingforfeedbackaboutthesession.
Socializ割tion
ミ①この胃之鞄ミ垂Ｑ図２度２這匡動︒︒
Thismeansexplainingtoclientswhatthecognitivemodel
isandhowitwillbeusedtotackletheirproblems.Equally
important, theirexpectedroleintherapyisoutlinedto
themalongwiththetherapist'srole.Ifsocializationisover‑
looked,clientsmightunderstandablybebewilderedbythe
therapist'squestionsandbehaviourandprovemoreresis‑
tanttoherclinicalinterventionsthanwouldnormallybe
thecase.AIso, ifclientshavebeenintherapy,particularly
non‑directiveapproaches, thenCTcouldcomeasa'culture
shock' ifthewayisnotpreparedthroughsocialization.
Feedback
Feedbackisobtainedduringthesessionandattheendof
it. In-sessionfeedbackenablesthetherapisttoascertainif
thepointsshehasbeenmakingareunderstoodbythe
client (forexample, 'Canyouputthethought-feelinglink
intoyourownwords?')andcorrectanymisunderstandings
thatmayhavearisenl'Thankyouforthefeedback,but
cognitivetherapydoesnotsaythatclients'problemsare
solelycreatedintheirheads. ImayhaveexplaineditincorrectlytLetmetryagain').End-of-sessionfeedbackasksthe
clienttocasthiseyeoverthesession('Whatwashelpful
andunhelpfulabouttoday'ssession?'). Itisimportantfor
thetherapisttoreactnon-defensivelytoclients/ criticisms
ofherortherapy. IfshedoesreactnegativelytosuchcriticismitmaywellindicatetoclientsthatonlyPositivefeedbackisreallywanted.Feedbackisanimportantpartofthe
14
opennessandcollaborationofCTandcommunicatesto
clientsthattheirviewsaretakenseriouslybythetherapist.
TimeLimited
Duetoitsactive, structured,collaborativeandgoal-directed
stance,CTforuncomplicatedcasesofanxietyanddepres-
sionusuallyrequiresbetween4andl4sessionsIBeck, 19951
whileWellsI1997) suggeststhatatypicalcourseofCTfor
anxietVisbetweenlOandl5sessions・Forchronicproblems
suchaspersonalitydisorders'Davidson (20001points to
9monthsorlongerforclinicallyimportantchangestooccur.
Homework
confidenceinbecomingtheirowntherapistisderivedfrom
carryingouthomeworkassignments.Burnssuggest'that
compliancewithself‑helpassignmentsmaybethemost
importantpredictoroftherapeuticsuccess｢ ￨1989: 5451.If
someclientsdonot liketheword'homework' ｢ thenthe
therapistcanusealternativessuchas 'real‑lifeactivities' ，
'betweensessiontasks/orBurns' 'self‑helpassignments｢.
BecomingaSelf-Therapist
TheultimateaimofCTisforclientstobecometheirown
therapistbyusingthecognitivemodelforpresentandfuture
problem-solving.Astheclient'sproblem-solvingabilities
increase, thetherapistcanbecomelessactiveinguiding
therapyandtransfermoreoftheresponsibilityfordirecting
15
■
thinkinganddevelopingmoreadaptiveandhelpfulwaysof
thinkingandbehaving.Muchofclients' competenceand
○く①﹃ミの言
Thesearethecognitiveandbehavioural activities that
clientscarryoutbetweensessionsbasedonwhatwasdone
inthesession.WithCT's emphasisonreality‑testing,
homeworkisthelogicalwayofcarryingoutthisfunction.
Homeworkprovidesopportunitiesfortestingmaladaptive
ittoherclient.Thetransitionfromclienttoself-therapist
canbematchedbythetherapist'stransitionfromtherapist
toconsultantorcoach. Independenceandself-relianceare
explicitclientgoalsinCTIWeishaar, 19931.
RelapsePrevention
三段滿冒之応ミ雪旦里①ニト①室這匡画︒︒
Bybecomingtheirowntherapists, clientscanapplywhat
theyhavelearnedtofutureproblemstheymightencounter.
Intheclosingsessionsoftherapy, anticipatedfUturedifficultiesarepinpointedandcopingstrategiesarerehearsedto
dealwiththem.Boostersessionscanbearrangedtomonitor
clients'progressandfocusonanyproblemstheyarefinding
hardtodealwith.'Ibpreventorreducerelapse,clientsneed
topractisetheirCTskillsasawayoflife(Becketa1., 1993).
Inthischapter,wehavepresentedanoverviewofCTtheory
andpracticeandnowturnourattentiontoassessingclients'
presentingproblems.
Notes
1
ViktorFrankl, aneminentpsychiatristwhosurvivedAuschwitz
wrote
Wewholivedintheconcentrationcampscanrememberthe
menwhowalkedthroughthehutscomfortingothers, giving
awaytheir lastpieceofbread.Theymayhavebeenfewin
number,buttheyoffersufficientproofthateverythingcanbetaken
fromamanbutonething: thelastofthehumanfreedomstochooseone'sattitudeinanygivensetofcircumstances, to
chooseone'sway.(1985:86)
Despitethemostappaliingand inhumanconditions, amoral life
wasstillpossibleforsomeinmatesintheNaziconcentrationcamps
andtheSovieigulagsystemratherthanacollectivedescent intoa
dog-eat-dogstruggleforsurvival (.Ibdorov, 1999)｡
16
2. Cognitivetherapyisoneofmorethan20approacheswithinthe
cognitive-behavioural tradition(MahoneyandLyddon, 1988).CTIs
themostpopularandbestvalidatedformofCBT
3o Gilbert (2000a)objectstotheword!error'as it impliesthereisa
correctwayofthinking(Gtheclientiswrongandthecounsellorisright').
Tbsidestepthisthornyissue, hesuggestsusingnon-contentious
expressionssuchas !anxiousthoughts' or @depressivethoughts'
insteadof $cognitiveerrors'.
4. Technicallyspeaking, $Schemasarethecognitivestructuresthat
organizeexperienceandbehavior;beliefsandrulesrepresentthe
contentoftheschemasandconsequentlydeterminethecontentof
thethinking, affectandbehavior'(Beck,FreemanandAssociates,
1990:4)．
5. Socraticquestioningcangivetheimpressionthatthetherapisthas
anendpoint inmindsuchastorevealaclient'scorebeliefabout
endpoints.However,Welisexplainsthat
（1997:56）
、
「
￨nourview,experiencedcliniciansusuallyhaveagoodideaofthe
cognitivedestinationofSocraticenquirybutshouldremainopen‑
mindedthattheycouidbe,andsometimesare,wrongaboutapar‑
ticularendpoint.
6. inworkingwithpersonalitydisorders, therapistsspendmoretimeon
theclient'sdevelopmentalhistoryand℃hildhoodexperiencetends
tobemoreimportantsincemaladaptiveschemas,establishedearly
inlife,playadominantroleinmanyareasoffunctioning' (Weishaar,
1993:74)．
17
■
Myownview...isthatacombinationofbothknowingwhere
togo, butallowingtimetoexplorethepatient'sevidencefor
thoughtsandforthepatienttogeneratesolutions isdesirable.
Ｏくの﹃ミの葛
himself({ ￨ 'mnogood').Padesky(1993)arguesthatthebestformof
guideddiscoveryassumestherearenopreconceivedanswersor
篭
鑑j： ：
AssesSment
蕊､賛蝋簿
Wells I1997) suggests thatassessment inCTconsistsof
threebroadcomponents:
l. Adetaileddescriptionofthepresentingproblem.
2. AnABCcross‑sectionalanalysisoftheproblem.
3.Alongitudinalassessmentlunderstandinghowpastfactors
contributetothepresentproblem) .
Theinformationcollectedfromthesethreecomponents
makeupthecaseconceptualization.'Alongsideconducting
theassessment, thetherapistneedstostartteachingher
clientsthethought‑feelinglink/orthecognitivemodel.
TeachingtheCognitiveModel
Duringthefirstsession, thetherapistintroducesthecognitive
modelsoclientscanmakeanearlyStartindetectingtheir
negativethoughtsandhowthesethoughts influencetheir
feelings.Forexample, someclientsmightbeanxiousabout
attendingtherapyorthetherapistmightnoticeamoodchange
duringassessment.Bothofthesesituationsprovidethethera‑
pistwithanopportumtytoteachthemodel.Forexample:
刀7e/ap/si
Whenlaskedyoutotellmemoreaboutyourproblem
yousigheddeeplyandstaredatthefloor.Whatwas
C//enr
goingthr･oughyourmindatthatverymoment？
Thingsinmyl ifeseemsooverwhelming. l don'tthink
therapyisgoingtohelpme.
TbelapﾉSr：
C"eni:
Andwiththosethoughtsinmind,howdoyoufeel？
Isupposelfeelasenseof :What'sthepoint?'
[777ec"enr/7asnofanswe/ediheq"es"Onof加whebe/s: /7e
力assI"Jp"edanoif7er"7oUg/7r.SeeC/)apfer3/bramscussﾉonof"7e
醐施尼ncesberween"7o"ghisandibe"ngs.］
7 herap/Sf:
C"enf:
777elap/sr:
Okay, you'vegivenmeanother thought @What'sthe
point?'toaddtoyourothertwothoughts, :Thingsinmy
lifeseemsooverwhelming'and@ldon'tthinktherapyis
goingtohelpme'.Nowwiththosethreethoughts in
mind，howdoyoufeei？
[g/"mMDepressed"
Whenyouhavenegativethoughtstheseleadtonega‑
tivefeelingslikedepression.Doesthatseemplausible
toyou？[C"enrnods､1Couldyouput inyourownwo｢ds
whyit isplausibIetoVou？
Well, ifyouseethingsasallnegativeandgloomylike
77Teﾉap/Sr:
Now, justsayforargument'ssakethatyouthought
therapycouldhelpyou,Wouldyoufeelanydi什erent？
ldo, thenyou'reboundtofeelprettybad.
C//enr:
￨'dfeelabitbetter.
777eﾉap/Sr:
Whatthoughtorthoughtswouldnowbegoingthrough
yourmindtohelpyoufeel
C"enr;
777eﾉapjSr:
abitbetter,？
Well, thingsIikelTherapywon'tbeawasteoftime'and
KMaybethere'shopeformeafteral1'｡
Good.Wufeelasyouthink[iapp/nghead] isapoint l
willcomebacktofrequentlyoChangethewayyouthink
aboutyourselfandevents inyour lifeandyou'li feel
di什erentlvaboutthesethingsOkay？[C"enrnods.］
Anotherwayofteachingthecognitivemodel,aftergaining
aninitialunderstandingof theclient'sproblems, is to
bedidacticIBlackburnandDavidson! 1995).Adidactic
approachwasshownatthebeginningofChapterl.Using
thisexampleofthreepeoplereactingdifferentlytolosing
theirjobs, thetherapistwouldseektoshowtheclienthow
themodelappliestohisownexperiences Iforexample｢ 'Is
thereanotherwayoflookingatexamfailureinsteadof
l9
進のいのいいヨ璽耳
C"enr:
condemningyourselfasafailure？Dotheotherstudentswho
failedall seethemselves inthesamewaythatyoudo?') .
After thefirst session,wewouldsuggest thatusingthe
clientIse"eriencesratherthanemployingmoredidactic
examplesisprobablythebestwaytokeepmakingthought‑
feelmglinks.
TheUseofMeasures
Measuresareusedtoassesstheseverityofclients' pre‑
sentingproblemsandactasabaselinetohelpdetermine
ミの垣２コ三町Ｅ語Ｑ因む巽烏のミ﹄這画︒︒
clients'progressduringthecourseoftherapy. 'IWoofthe
mostcommonlyusedmeasuresinCTaretheBechDep7es‑
sio"I"veyzroりﾉ IBDI) IBecketa1. , 1996)andtheBecltAJTxiety
I7zve"ro7yIBAI)IBeCkandSteer,1990).Thesemeasuresare
giventoclientstofill inbeforethestartofasessionand
provideanobjectivewayofmonitoringaclient'smoodlfor
example,areturntohigherscoresontheinventoriesusu‑
allyindicatesasetbackorrelapse1 .
Someclientsmightbereluctanttofillouttheinventories
￨ 'Paperworkisn'tgoingtogetmebetter' ￨; ifthisreluctance
issmlevidentafterthetherapisthase"lainedthepurposeof
inventories,thenshecansuggesttheconstructionofamood
scaleofl‑10orl‑100asanalternativemoodcheckl｣My
anxietyhasgonerightupagaininthelastcoupleofdays;
Iputitateightornine'l. Inventoriesandmoodscalesare
usedalongsideclient'sreportsoftheirsymptoms,difficulties
T
andprogress･
TheClient
InordertodemonstratehowaCTassessmentiscarriedout
andatreatmentplanisderivedfromit,wewillintroduce
20
aclient, John,whoseprogressintherapywewillfollow
throughthebook.Johnwasinhisearlyfiftiesandworkedas
aGPHewasmarriedandhadtwochildren,bothgrownup.Hehaddiagnosedhimselfashavingsocialphobia(11!ve
readbooksaboutitandbeenresearchingthesubjectonthe
internet'l.Wellsstatesthat
acentral characteristicof socialphobia is thefearof
〜
negativeevaluation｢whichthesocialphobicanticipateswill
resultfromsomeformoffailedperformance...[theperson
has]astrongdesiretoconveyafavourableimpression
ofoneselftoothers, andthisisaccompaniedbymarked
insecurityaboutone'sabilitytodoso.(1997: 167,169)
atthelastminutetoswitchtoface‑to‑faceCTHesaidthe
problemhadbeenwithhimalongtimeandwhileitdid
notstophimhavingasuccessfulandhappylife, 'Iknowit's
alwaysatthebackofmymind‑whenisthisproblem
goingtogoaway?'.Hewasdesperateforhelp,whichshowed
inhisagitatedstateduringthefirstsession,andsawCT'as
mylastchancetogetridoftheproblem'.
MakingaDiagnosis
Inordertohelpcliniciansmakeanaccuratediagnosisonthe
basisofaclient'spresentingsymptoms,cognitivetherapistsconsult77zeDiqg7zos"cq"dSrα"s"cqIMcmHaIofMe"ml
Disorde"(DSMIV) IAPA, 19941publiShedbytheAmerican
PsYchia廿icAssociation.Thislistsdiagnosticcriteriaforawide
21
あいの①いいヨ①︒鳧
Johnsaidhehadbeenintherapyforseveralmonthsbut
foundthenon‑directiveandpast‑centredapproachofthe
therapyunhelpfulandfrustrating (!Iwantedaction,not
endlessdiscussionandreflection' l.Hehadbeeninvesti‑
gatingusingaCTLbasedcomputerprogrambutdecided
rangeofmentaldisorders.IfachentIspresentmgsymptoms
meetthediagnosticcriteriaforaparticulardisorder｢thenthe
cliniciancanbesatisfiedaboutthenatureoftheproblemshe
isdealingwith. Inlohn'scase￨hesaidhehadsocialphobia,
butdidhemeettheDSMIVcriteriaforit？
TheDSMIVstates that 'theessential featureofSocial
三のこ２．乏町昌蚤Ｑ飼芯全ト①筐廷巨画︒︒
Phobiaisamarkedandpersistentfearofsocialorperfor‑
mancesituationsinwhichembarrassmentmayoccur' (APA1
1994:411).John'sfearinvolvedonesocialsituationrather
thanseveralormany ldiscretesocialphobia):namelyl as
chairmanofacommittee, partofhisdutiesweresignmg
cheques1minutes,documents・Whenhedidthis, theother
committeememberswouldbewatchinghim: 'They'llsee
myhandshakingwhenl'msigning.They'llthinkl'maner‑
vouswreck.MYcredibilitywillbedestroyed'・Johncalled
thissigningceremony'beinginthespotlight'.
Johnpushedhimselftochairthemeetingsthoughhe
dreadeddoingso.Hesaidhisfearwas 'overthetopand
irrational'butthatrealizationdidnothelphimcopewith
thesituationanybetter.Severaldayspriortothemeeting,
hewouldbegrippedbyintenseanticipatoryanxietywhich
disruptedhissleeppattern,familyrelationshipsandwork;
hedespairedofevergettingoverhisproblem.John'sself‑
diagnosiswascorrect:hemettheDSMIVcriteriaforsocial
phobia(seeBox2.1) .
Box2.1DSMIVDiagnosticCriteriaforSocial
Phobia(Summary)
1.Amarkedandpersistentfearofoneormoresocialor
performancessituations.Thepersonbelieveshe/shewillact
r
‘
inawaythat ishumiliatingorembarrassing.
2. Exposuretosuchsituationsalmostalwaysprovokesanxiety"
22
Box2．1Continued
3.
Thepersonrecognizesthathis/herfear isexcessiveor
4.
Thefearedsituationsareavoidedorenduredwithintense
5.
Avoidance,anxiousanticipationordistressinthe
unreaso､able、
anxiety.
actualsituationsignificantlyintelfereswiththeperson's
normal functioningorthereismarkeddistressabout
havingthephobia.
CaseConceptualization(Initial)
Figure2､1
1nitialCaseConceptualizationofJohn'sSociaIPhobia
EarlierExperiences
Developmental
historyforming
John'scognitive
vulnerabi l itvto
futuresituations
Beinginthespotlightatschoolandcollege
Punishedatschool forgettingthingswrong
Worriedatcollegethathemightmake
Iafoolofmvself'andbeostracized.
Tacitmessage: ｣Don'tshownervousnessto
others'.
wherehis
↓
nervousness
mightbeevident
CoreBeliefsandUnderlyingAssumptions
@I'mweak' (corebelief).
{lf lkeepmyselfundercontrol, thenl'llbe
seenascompetentandstrong' (positive
assumption).
(Con"nuedノ
23
垂いい⑯いの一コ①．﹃
ThisputsahumanfaceonthediagnosisIandtherebyavoids
seeingtheclientasa 'label' l bythetherapistandclient
workingtogetherto'drawapicture'ofthepastandpresent
factorsassociatedwiththeclient'sproblem(seeFigure2､11.
Figure2､1
Continued
llfIshowweaknessornervousnessto
others, thenl'llberejectedandridiculed'
(negativeassumption).
4Imustcomeacrosstoothersasa
confidentperson' (rule).
↓
StrategiestoAvoidActivatingCoreBelief
Workhard･
■
菫①鐘２コ之町ミ当Ｑ何﹄の垂トの屋茎宮口︒︒
Project imageofstrengthandresilience
Removeimpelfectionsinmyself.
Ascendsocial ladder．
PrecipitatingEvent
↓
Beingappointedchairmanofan important
committee．
↓
CoreBeliefandNegativeAssumption
Activated
Weaknesswillbeexposedleadingto
ridiculeandrelection.
Situation
Factors
maintaining
John'sproblems
↓
Waitingtosigntheminutesofthelast
meeting(beinginthespotlight).
Negativeautomaticthoughts(NATs):
4Whar/fmyhandshakesunConim/値b/y?'.
ﾉｿ/beseenasnervousandourofconかひﾉ
汎"yc尼北/"〃WI"bedeSirOVed'.
G777eyWon'fWanrmeaScha/rman'.
24
Figure2.1
Continued
"
Self‑consciousness
iTheycanseehow
nervousIfeel'.
1
1
、
ヤ
ヤ
当
"y
behaviours
Keeptight
controlof
himself.
Rushsigning
ofminutes.
迦旦iQal
SMrnptOmS
Heartracing.
Mindspinning.
Tightnessin
chest.
‑ITembling.
Emotion
lntense
anxiety/near
panic.
PrecipitatingEvent
ABCAnalysis
JohnsaidthatitwasthefirStfiveminutesofchairinga
meetingthatprovokedthegreatestanxietyLTheinformationfromthistimeperiodprovidedanABCanalysisofthe
situationaswellasdemonstratingthepowerful impactof
25
垂的の①の伽ミ⑩︒年
Thisisthecriticalincident Isayl thelossofajobortheend
ofarelationshipl thattriggerstheclient'spresentingprob‑
lemldepression, forexamplelandisthereasonsheseeks
therapy. Inlohn'scase,hehadalwaysbeentryingtosup‑
presshisanxiety'outofexistence'andwhenheaccepted
thechairmanshipofanimportantcommitteeasa'stepup/
inhissocialcareer, thisreactivatedhislong‑heldfearof
!beinginthespotlight' (thisfearwasthereasonhesought
therapy).The'spotlightmoment'waswhenhehadtosign
cheques,minutesorotherpaperwork.Hefearedthathe
wouldnotbeabletostophishandfromshakingandwould
thereforebeexposedas'weakandoutofcontror.Johnwas
determinedto'makeago'ofbeingchairmaneventhough
hewould'putmyselfthroughhelleachtimeldoiti.
thoughtonfeeling.ThetherapistwroteanABCexample
onawhiteboardinherofficeIseeFigure2.2):
Figure2.2
John'sABCExample
(A)
Antecedents/Situation
(B)
Thoughts/Beliefs
(C)
Consequences
Emotion
Waitingfortheminutes
oftheiastmeetingto
bepassedtohimfor
4What ifmyhand
They'll thinkl 'ma
一両塁２コｚ町昌語旦応︑①こト①ミ﹄這画︒︒
nervouswreck.
sIgning｡
Intenseanxiety
shakesuncontrollablv？
Behaviour
Thev'IIseelcan't
controlmvself.
Maintain
They'IIwantanother
tightcontrol
chairman｡
ofhimself.
l,ll losealI
credibilitywiththem'.
JO/7，
[pom伽grof/7eしW7/reboaﾉd] l knowit'smythinking
thatmakesmesoanxious in thesituation‑ I 've
gotnoargumentabout that‑butwhat doldo
about it？
刀7eﾉapjsr
We'II cometoanoutlineoftreatment inamoment｡
￨ neediofindoutsomemoreinformationaboutthe
problem.Canyoutellmewhatactuallyhappenswhen
yougettheminutes？
Jo/7n
Well, ￨ 'mgrippingmypenverytightly, I snatchthe
minutesfromthesecretary‑I'msureldon'tactually
snatchthembut itfeelslikeit‑andsignthemathigh
speedwhichproducesan indecipherablescrawl
which l feel reflectsbadlyonmetoo.Acompetent
chairmanincontrolofhimseifwouldproducealegible
signature.
26
刀7erap/si
Soarethesefirst fiveminuteswhatyoucall being
Jo/7n:
Yes.Oncel 'vesignedtheminutes, ￨ rapidlycalmdown
jnthespotlight,？
andcannowfocusonthemeeting,nowthat l'moutof
thespotlight.
Johnsaidhehadnotroublesigningdocuments, cheques,
etc. infrontoffamily, staff,patientsandfriendsbuthe
hadsome'runins1withafewcommitteemembersand'I
donitwanttogivethemanyammunitiontouseagainst
me｢ andsawhimselfas 'sociallVandintellectuallVinfe‑
エ
ユ
rior' toseveralothermembers‑ 'Idon'twantthemto
thinkbadlyofmebycomingoverasamanwhoisnotup
tobeingchairman'.Aftereachmeetinghewouldbrood
onhisbehaviour （'Didtheyseehownervouslwas？I'm
ユ
ノ
ュ
selfthatthesolutiontohisproblemwastoholdhimself
eventighterincheckatthenextmeeting.Heknewthis
solutionwasnosolutionaJsoonerorlaterlwillexplode
withthetension.Thenlreallywillmakeaspectacleof
mvself'.
MaintainingFactors
inJohn'sSociaIPhobia
Unhelpfulassumptions:
ThesereinforceJohn'snegative
viewofhimselfwhenhethinksaboutorentersthesocial
situation: 'Iflcan'tkeepcontrolofmyself! thenl'llbeseen
asweakandpathetic'; 'Ishouldhavegotoverthisproblem
bynow'.
Negativeautomaticthoughts(NAIS): 'Whatiflcan'tstop
mVhandfromshaking？I'llberidiculedasanervouswreck．
I'llbeaskedtoresign.Mycredibilitywillbedestroyed'｡
27
遅のの①いい︒︾①コヰ
surethevdid.I'mamess'landthentrvtoconvincehim‑
Safetybehaviours: ThesearebehavioursthatkeepJohn
'safe' fromhavinghisfearsreahzedinthesocialsituation,
forexample!desperatelytryingtokeephimselfundercontrol
andrushingtosignhisnameto'getitoverwith'.
Self-consciousnessandnnmdreadmg: Assumingthathow
hefeelsinternallyl'anervouswreck')ishowheisperceived
byothersatthemeeting-'Iflfeelsowretched,thensurely
theycanseethat'.Believingthathispublicselfmirroredhis
privateselfincreasedJohn1sanxiety.
菫のこの旨之殉ミ語旦図①塁トのミ廷↑＆ＣＱ
EarlierExperiences
(LongitudinaIAssessment)
TheonlypastlinksJohncouldmakewithhispresentproblemwas 'beinginthespotlightat school. The teacher
wouldstareatmeorstandovermeiflhaddonesomething
wrongandlwouldusuallybephysicallypunished・ Idevel‑
opedaphysicalterrorofbeinginthespotlight'.Atcollege,
beinginthespotlightnolongermeantphysicalpunishment
buthewasworriedaboutbeingseenbytheotherstudents
asa 'nervousperson'.Hethenmadetheconnectionwith
the'socialterror'hefeltnowatmeetings(potentialcensure,
ridiculeand/orostracisml .
CoreBelief(s)
Thesearefundamentalbeliefs thatpeoplehaveabout
themselves, othersandtheworld.Corebeliefsaboutthe
selfareusuallyregardedas 'factsaboutme'. John'score
beliefwas'I'mweak'・Heviewedbeingscaredandnervous
asaweakness, especiallyassomeoftheotherschoolboys
'stoodupwell tobeingpunishedwhentheywereinthe
spotlight'．
28
Underlying(Conditional)
Assumptions/Rules
jThesefunctionasguidelinesforlivingorgroundruleSfor
operatingintheworld,giventhetruthofthe"bottomline"
[corebelieq'(Fennell, 1997:4).Assumptionsandrulesseek
toupholdorreinforcethe'bottomline! ratherthanseekto
changeitforaflexibleandcompassionatecorebelief ifor
example,｣Iflshownervousness! thenobviouslylhavesome
vulnerabilities.I'mastrongpersonwithvulnerabilities!not
aweakpersonbecauseofthem' ).
'Iflkeepmyselfundercontrol! thenl'llbeseenascompe‑
tentandstrong' (positiveassumptionl .
。
'Iflshowweaknessornervousnesstoothers, thenl'llbe
rejectedandridiculed' (negativeassumption)｡
Imustcomeacrosstoothersasaconfidentperson' {rulel.
・
StrategiestoAvoid
ActivatingtheCoreBelief
Becksuggeststhatmostclients 'operateaccordingtotheir
positiveassumptions' (1995: 1411.Behaviouralstrategies
aredevisedtooperationalizetheseassumptionsandaslong
asthesestrategiesaresuccessful,theyavoidactivatingcore
beliefs.John'sstrategieswereto:
●
●
●
●
Workhardtogetaheadinlife.
PrQiectanimageofbeingstrongandresilient.
Removeanyimperfectionsinhimself.
Developimportantsocialcontactsinordertoascendthe
social ladder' lthebeliefbehindthisstrategywasthat
socialpositionequalledstrengthofcharacter).
29
遅いの①いい一コのご鼻
。
SuitabilityForShort-Tbrm
CognitiveTherapy
Aswediscussedinthefirstchapter,muchcanbeachieved
inarelativelyshortspaceoftimewithuncomplicatedcases
ofanxietyanddepression・ '1bdeterminewhichclientsare
suitableforshort‑termCTISafranandSegal (1990)deviseda
scaleforthispurpose.TheitemsonthescaleareratedO‑5;
thehigherthescores, thegreaterthesuitability
1
Awarenessanddifferentiationofemotions. 1ohnwasaware
３
４
−
ｂ
一両こ２コ之町ミ語旦恂﹄①垂ト①詮轌這句０︒
２
Accessibilityofautomaticthoughts・Johnhadnotrouble
detectingthese151.
ofandabletodistinguishbetweenanxietylembarrassment,
angerand'feelingdown' (51 .
Acceptance ofpersonal responsibility. 'I accept full
responsibilityformyproblemandtacklingit' (5) .
Compatibilitywithcognitiverationale.Hehadreadseveral
booksonCTandreadilyacceptedthecognitivemodeland
whatwasrequiredofhimintherapy(51.
Alliancepotential lin‑sessionevidencel. Inthefirstsession
{butnot laterones)' Johninsistedonachievingwhatthe
therapistsawasanunrealisticgoalandhewasreluctant
todiscussotheroptionsofferedbyher(seetreatmentplan
onpp、 31‑21 ．Atthisstage! thiJstickingpoint'maynot
havebodedwellfordevelopingaworkingalliancel31.
6
房
／
Alliancepotential (out‑of‑sessionevidence).Johnhadgood
relationshipswithhisfamilylfriendsandcolleaguesI5).
Chromcityofproblems.EventhoughJohn'snervousnesshad
beenalong‑standingworry‑a'stonemtheshoeirritant'as
hecalledit‑ithadnotimpairedhislifeinanYsignificant
way(5) .
8
Securityoperations. Thisreferstopsychologicaland/or
behaviouralactivitiesthatclientsmayengageintoavoid
30
fearedoutcomesoccurringandpreserveasenseofsafety;
however, theseactivitieshelptoperpetuatetheirproblems.
WhileJohncouldseethe 'eminentsense' ingivinguP
theseactivities,hewasworriedthathewould'getoutof
controlifldon'tholdmyselfincheck' |4).
9
10
FocalitV.ThisistheabilitVtoremainfocusedonaspe-
cifictopic.Johnfocusedonhisproblemlikealaser (5).
Clientoptimism/pessimismregardingtherapyJohnfeltit
washis 'lastattempt' toovercomehisproblemaspreviousattemptshadprovedfruitless.Oncloserexamination,hiscommentwasacryofdespairratherthana
genuinelastattempt.HewashopefulthatCTwouldhelp
him(41.
Atotalscoreof46indicatedthatlohnwasanexcellent
Measures
Measuresthatwereusedintheassessmentandtreatment
ofJohn'ssocialphobiaincludedtheSociqICogrzi"o"sQzles加""αかeISCQ) IWellseta1., 19931,It"o/IVEgWive酌α1瓦α伽〃
IFNEIIWatsonandFriend,19691,SociqIAvoi血"ceq"dDis‑
"esSISAD) IWatsonandFriend,1969),SociqIPJzobiqQzJes加刀一
"αかe(SPQI ILeahyandHolland20001andtheBechA"xieb'
"zvemoりﾉ IBAI) IBeckandSteer! 19901.
TTeatmentPIan
Oncetheassessmenthasbeencarriedout,thenextstepisfor
thetherapistandclienttoagreeonthelatter'stherapeutic
goalsandthestepsrequiredtoachievethem.Whenit
31
垂切の①の切喜︼⑩﹃乱
~
candidateforshort-termcognitivetherapy.
cametodiscussinggoals'Johnwasadamant! initially, that
'eradicatingnervousnessfrommypersonalityismygoal'.
Discussionfocusedonwhylohn'spreviousattemptshad
failedtoproducethisoutcomel!Idon｣tknow.Maybel'm
notdoingtherightthings,whatevertheyare'l.Thethera‑
pistwasreluctanttorepeatinCTapreviousstrategythat
hadsignallyfailedtoworkandthatwasalsocounter‑
therapeutic, inotherwordsitwouldreinforcetheclient's
ideathattotrulyaccepthimselfhehadtopurgehimselfof
hisperceivedweaknessesIJohnadmittedto 'beingsome‑
thingofaperfectionist'l.Afterlengthydiscussion,theclient
agreedtothefollowingtreatmentgoals:
１
２
３
４
−芯廷２コ三町ミ豈旦圃当①兵ト①量逹堂画◎︒
Cognitiverestructuring:modifyingkeyautomaticthoughts
andunderlyingbeliefsIacceptinghimselfforhisfallibility
insteadofcondemninghimselfforitl.
E"osinghimselftothefearofhishandshakingwhile
signingtheminutesandtheexpectedderisionthatwould
followbydeliberatelyshakinghishand.
Droppinghissafetybehavioursandreplacingthemwith
adaptivebehavioursItakinghistimetosigntheminuteswithouttryingtokeephimselfundertightcon廿olwhiledoingso) .
Learningprogressivemusclerelaxationtoreducethephys‑
icalsymptomsofanxietythat interferewithhisperfor‑
mancebut"orusingrelaxationasanewsafetybehaviour
tOノhide'hisnervousnessfromothers.
5
Elicitingaccurate informationfromthe environment
insteadofrelyingonhowhefeelsinternallytoguidehow
hebelievesheisbeingperceivedbyothersinthesituation.
Johnagreedtoacourseofsixsessionsinordertodeter‑
mineifCTcouldreallyhelPhimtoreducethefrequency!
intensityanddurationofhisanxietybefOre, duringand
afterhis ｣inthespotlight' terror.Moresessionscouldbe
negotiatedifrequiredbyhim.
32
In this chapter!wehavedevelopedan initial case
conceptualizationoftheclient'sdiscretesocialphobiaand
inthenext chapterweaddresshisnegativeautomatic
thoughts INATも)associatedwithit.
Note
1
Oneofthehallmarksofagenuinecognitivetherapist istheuseofa
caseconceptualization, not justtheuseofcognitivetechniques: :1t's
interestingthatmanypeoplelabelthemselvesCognitiveTherapistswho
usecognitivetechniques,butdon'thaveacognitiveconceptualization
{oftheclient'sproblems]' (Beck,quotedinWeishaar,1993:108)
淫いい⑯いい︒︾⑯．﹃
33
Elicitingand Exa咽ining
ngNegative
Autom aticTmo ughts
AswediscussedinChapterl,threelevelsofcognitions
(thoughtslareusuallytargetedforidentificationandevalu‑
ationinCTThemostreadilyaccessiblearethesituation‑
specificnegativeautomaticthoughts INAIblwhicharethe
subjectofthischapter. Sometimesthesethoughtscanbe
easytodetect.Forexample, apersonwithatrayoffood
tripsoverwhilewalkingtoatableinacrowdedrestaurant
andthefoodlandsonseveralpeoplesittingcloseby.His
mindisimmediatelyfloodedwithdistressingandnegative
thoughts: 'Ohshit! I'msuchaclumsybastard. I'malaugh‑
ingstock.1t'sadisaster.They'llthinkl'mdrunkorworse.
I'vegottogetoutofhere.Whydidthishappentome?'He
apologizesprofuselyandsomewhat incoherentlytothe
peoplehisfoodfellonandthenrushesoutoftherestau‑
ranttogainsomerelieffrom'myhorrendouslyembarrass‑
ingexperience'.Thepersonhasnotroublelatertellinghis
friendwhatwentthroughhismindduringhisembarrassing
勺
experlence.
Onotheroccasions,NAIbarenoteasytodetectbythe
chentbecauseheis'completelyunawareofthem;theyareso
muchapartofhisviewofhimselfandtheworldthatthey
donotappeardistortedorproblematic' IPersons, 1989: 1161.
Withsuchaclient, thetherapistwouldneedtohelphim
jtunein' tohisNAIbandunderstandwhytheyaredistorted
orproblematic,forexample, 'Whenthingsgowronginyour
life,coulditbethatthesethoughtsyouhave,"Thatistheway
italwaysis.Nothinglcandoaboutit",helptomaintain
yourlowmoodandpreventyoufromfindingsolutionsto
yourproblems?' Iftheclientagreesthatthesethoughtsare
problematic,thenfindingwaystomodifythemcanproceed
(iftheclientdisagrees' thenanexplorationoftherootsof
hisdisagreementisrequiredl.
ThetherapistcannormalizeNAIbbyhelpingclientsto
seethateveryoneexperiencesthemandtheyoften'popup'
whenwefeelupset. Suchthoughtsareusuallydismissed
orchallengedinsomeway3However,difficultieswithNAIb
startwhentheyarelmkedtoprolongedpsychologicaldistress,
aredifficultto'turnoff',arenotsubmittedtorationalrenec-
tionorempiricaltesting, seemplausibletothepersonand
andanumberoftechniquesarenowdescribedtohelpyou
dothis.
ElicitingNATS
AskingDirectQuestions
ThisisthemoststraightforwardmethodforelicitingNAIb:
,Whatwasgoingthroughyourmindwhenyoufelt[specify
emotion] inthatSituation?'Thisformofquestioningcan
quicklyestablishwhetherclientshavetheabilitytoidentify
suchthoughts.Avoidaskingvague, ramblingorconfusing
questions, suchas,'Whatdoyouthinkyouwerethinking
about inyourmindwhenyouwerefeelingthatwayin
thatsituation？Inotherwords1didyouhaveanynegative
thoughtsthatweregoingaroundinyourmindandthat
wereconnectedtohowyouwerefeelinginthatsituation?'
IAfrequentclientreplytosuchaquestionIsl is: 'Idon#t
knowwhatyoumean' ).Tbavoidbafflingclientswithsuch
verbositylaskshortanddirectquestionssuchas 'Whenyou
wereangrylwhatspecificthoughtswereconnectedtoyour
35
三の廻凰言⑩退こさヨ豊苛﹃寺◎匡廼雪厨
reflectthecontentofactivatedcorebeliefs('I'mafailure'l .
BeforeNAIbcanbeevaluated' theyhavetobeuncovered
anger?'or'Whatparticularthoughtsorimageswentthrough
yourmindwhenyoufeltanxiousinthatsituation?'
GuidedDiscovery
ThisreferstoaseriesofguidedquestionsaskedbythetherapisttohelpherclientsdiscoverinformationthatiscurrentlV
皇
outsideoftheirawareness.Thisinformationisthepresence
ofautomaticthoughtsandtheinfluencetheyhaveonmood
andbehaviour.Forexample,aclientsayshebecameangry
jfornoreason'whiletalkingtoafriend:
一両瞳の冒乏応ミ語且図①兵ト①ミ廷匡句︒︒
melap/sr:
Was it somethingthatyour friendsaidordidthat
triggeredyourange『？
C//eni:
Hedidn'tdoanythinghorribleorunpleasant.Hewas
justtalkingabouthowhappi lymarriedhewas.
777elapおｵ：
Howdidvourespondtothat？
C"eni:
777elap/Sr;
Istartedthinkingaboutmyownrelationships.
What specific thoughtsdidyouhaveabout your
C"enr:
7 he煩p/Sr：
Well, Iwasthinking@He'saluckyguy'.
WereyoucomparIngyourselfwithhi、？
relationships？
[777eil7erap/Sr/s/7ypoil7eSizi7g"7ai〃的ec"enr怠耐endba7LJcky
guy'"7e"maﾚbe"7ec"enfﾉSanun/uckyone.]
C//enf:
Verymuchso｡
7 77e虚pjsr：
C"e"r:
lnwhatspecificways？
Thingslike(Myrelationshipshaveall failed'and:Ican't
seemtofindanyonewhoreal lywantsme'.
[7 hec"enf /7asnowﾉevea/edrwoauroma北〃7oug/7おしW7jb/7"7e
坊eﾉaP/Srw"resonfhewh/reboaﾉdm/7eroMce.1
7 he虚p/sr：
C"e"r:
DidanyotherthoughtspopIntoyourhead？
[g""ng/7/Siee"7] :Why ishesohappyand I'mso
miserable？，
｢A"o"7erauroma"c"7ouq/7tl
ｰ
4
36
7he旧p/Sr：
lsthereananswertoyourquestion？
[Wheﾉ7c//enisPurr/7e/rauromar/cfhoug/7ism的eわ"nofques"oﾉ7s，
/7emfhemfotumihesequesr/ons/nfoc/earsiafemenIS.]
C"enr:
Yestherebloodywell is: &Noonewantsmebecause
I'munloveable' .
[777/sautomar/cif7oug/7fpo/nisiofhepresenceofacorebe//ef−7?m
un/oveab/e'J!
777efap/Sr:
nods1､CouldVouexplainthisIinktome？
Well ,whathewastalkingaboutstartedmethinking
aboutallmyownfailedrelationshipsandhowunhappy
lam.All thosethoughtscameintomyheadandmade
meangry.
777e旧p/sr：
Howdidyoubehavewhenyougotangry？
Cﾉ/enr:
Icut theconversationshort rather rudelyandthen
ruShedo什.lwasinsuchafoulmoodbythattime.
me虚p/sr：
Doyoustillbelieveyourangeroccurred fornoreason，？
C"enr:
Noldon't・ lt'sveryclearnowwhatwasgoingonwithme.
Throughcarefulquestioning,theclientisguidedtodiscover
forhimselfwhyhegotangrywhentalkingtoafriend.The
Presenceofacorebelief ('1'munloveable')wouldbediscussedbrieflybutnotusuallytackledintheearlystagesof
CTIseeChapter5).Thereasonforthisisbecauseclients
needtolearnandpractisetheirCTskillsontheirNAIb
beforeaddressingsuchanimportantissueascorebeliefs.
GuideddiscoverVisoneofthecornerstonesofCTIPadesky
andGreenberger,1995).
In-SessionEmotionalChanges
Changesinaclient'semotionalstatecanoccuratanytilne
intherapy; it isimportantforthetherapisttobealertto
37
ｚの︒閏言①シミ︒ョ豊苛︒５匡竺︾蕨
C//enf:
Dothesethoughts[po/""ngrorhew/1/feboaﾉd]explain
whyyoufeltangrywhentalkingyourfriend？［c"enf
theseobviousorsubtleemotional shiftsas theyarean
importantentrypointintotheclient'sthinking・Forexample,
whenaclientistalkingaboutarecentpartyshewentto,the
therapistasksher 'ifshegotoffwithanyone'.Theclient
shakesherheadandstaresatthefloor:
777e/ap/Sr
C"enr;
Howdoyoufeelatthismoment？
Reallydown.
7 helap/Sr
What'sgoingthroughyourmindatthisverymomentto
C"enf
makeyoufeel reallydown，？
$Noonewantedtogeto什withme.Thevneverdo. 1'll
aIwaysbeonmyown' .
ず
三の廷２コ之町ミ当旦阿﹄の垂トの皇置亡句○○
Theclient'srepliesare'hotcognitions' : thesearethoughts
'thataremostconnectedtomoods…andconduct the
emotionalcharge' IGreenbergerandPadesky' 1995: 551 .
Hotcognitionsarethemost importantNAIbtoelicitand
tackle.
WorstConsequencesScenario
(Wells,1997)
Thisinvolvesaskingclients/ 'What'stheworstthatcould
happen if… {your fear is realizedl?' Padeskyand
Greenbergerl1995) statethatthisisoneofthebestquestionstoasktoidentifyhotcognitionS inanxiety. InthiS
example,aclientisanxiouslyawaitingaletterregardinga
recentjObinterview:
7 77eﾉapjsr：
C//enf:
7 y7eﾉap/sr:
Whatareyouanxlousabout？
Thatlmightnotgetthejob.
What'stheworst thatcou1dhappen ifyoudon'tget
thejob？
C//enr:
1f ldon'tget it, itwillbemytwenty‑firstjobrejection.
[刀)ec"enrjssiarmgabcr庖的erihan/ook"79ar/7/Swoﾉsrcase
scena"Obasedo"/7brwen〃‑ｶﾉsr/ob'e/ecr/o/7.]
38
777eﾉ臼p/Sr
n
Butwhat'sthewor~aspectofyour twenty-first job
rejection？
C"eﾉ7t：
Myspiritwill bebrokenand l 'il giveup trying to
findajob. l'll lustdrift through lifedepressedand
unmotivated.
[刀1eC//en指/7offhoughisareuncovered.］
Imagery
canthenasktheclientwhatisthemeaningsheattaches
toherimageof 'shrinkingintoinsignificance' inorderto
discovertheNAIb: 'Myviewswillbeseenasunimportant.
I'mnotasintelligentastheyare｢.
Imagerycanhelpclientstorecreatepastsituationsinorder
toactivatenegativefeelingandassociatedhotthoughts. It
isimportantthatclientsdescribepastsituationsinthepre‑
senttense,asiftheyarehappeningnow:
77TeﾉapﾉSr
C"enr
me値p/St
CIoseyoureyesandnowtrytorememberasvividlyas
possiblewhat itwasthatyourbosssaidthatyougotso
angryabout.lmaginethesituationishappeningrightnow.
Okay.|'minhisofficediscussinganewproject l'm
assuminglwillbetheprojectleaderasusual.Thenout
ofthebluehesays,:|'veaskedChristotakethelead
onthisone'. l'mfuriousinsidebuttrytocontrolmyself
andask:iWhythechange?'Hereplies,(Weneedsome
newthinkingonthisprojectgivenitsimportance'.inod
myheadbutlwanttotearhiso廿．
Whatarethespecificthoughtsgoingthroughyour
mindatthismomenttomakeyousoangry？
C/reni:
￨ feelhumiliated.
39
之①垣豊ご巾エミ◎ヨ豊苛﹃寺︒こい言の
Theword'cognition' referstoimagesaswellasthoughts.
Someclientsmayfinditeasiertoelicitimagesratherthan
thoughtsinparticularsituations: 'I'mnotsurewhat l'm
thinkingbutlcanseemyselfshrinkingintoinsignificance
whenl'mtalkingtoveryintelligentpeople'.Thetherapist
[Thec"enｵﾉ7asnoranswefediheques"on,]
777e垣p/sf：
C"enf:
That，showyoufeel,butwhatareyouthinking？
1'mthinking, :Ybubastard! Ybu think l'mnotgood
enoughtoleadthisprOjectlcanonlybetrustedwith
thecrapones.He'sgotmorebloodyrespeci forthe
cleanersthanhehasforme.Whatatwo‑faced,back‑
stabbingbastard! '
[/magery/7as/7emed"7ec"e"rioPinPo"7f/7/Sve〃/7Or"7OUg/7rS.]
ExposureExercises
Theseinvolveclientsenteringsituationstheyusuallyavoid
一両廷の盲三町昌語Ｑ侭句全ト①ミ逹巨動︒︒
orengaginginactivitiestheyusuallyavoidinthosesitua‑
tionsinordertouncovertheiranxiousthinking‑suchthink‑
ingcanbedifficulttouncoverwhiletheyaresittinginthe
safetyofthetherapist'sofficeandstandardquestioning
and imageryexerciseshavefailedtoprovideabreak‑
through.Forexample, aclientwhosaysshewouldfeel
uncomfortablebuyinga 'sexybook' butdoesnotknow
why, isaccompaniedbythetherapisttoalocalbookshop.
Standinginthequeuewiththebook,sherevealsheranxious
thoughtstothetherapist: 'They[thestafflwillthinkl'ma
bitofapervert.Patheticandsex‑starved.Asadcase・They'll
besmirkingwhenlpayforit.Icouldn'tbeartogothrough
that'.TheclientPutthebookontheshelfandwalkedoutof
theshop.Thesethoughts,nowuncovered,wereexamined
backinthetherapist'soffice.
TherapiSt-GeneratedSuggestions
Whensomeclientsareunabletoproduceanyautomatic
thoughts, it isunproductivetokeeppressingthemwith
'Whatwasgoingthroughyourmind?' typequestionslif
youdo, theirreplywillbe 'Idon/tknow' inincreasingly
exasperatedtones!l.Instead,makesuggestionsbasedon
yourclinicalexperienceofworkingwithsimilarproblems.
40
Forexample,aclientwhoisstrugglingtounderstandwhy
IIwouldbedevastatedif l gotpoor feedbackformy
presentation' isofferedsomesuggestionsbythetherapist:
7Maybeyou'llbelieveyourcredibilityhasbeendestroyej,
youinavelousyrapportwithanaudience,you'reunlikeable
6ryouhavebeenrevealedasaphoneyfornotknowing
yoursubject' Itheclientisjoltedbythelastsuggestion-
冬
'That'stheone! ' ).
Makingsuggestions isnotputting ideas intoclients'
heads:clientsadoptthetherapist'ssuggestionliftheycon‑
siderittobehelpfullbye"lainingwhyit isrelevantto
theirproblemsThus' thetherapist'ssuggestionsusually
d
wrong.Thisencouragesherclientstocorrectherifsheis
wrongandtheircorrectionsoftenprovidetheclinically‑
relevantNAIb.
InteroceptiveExposure
Thismeansinducingfearedbodilysensations (breathlessness,dizziness) inclientswithpanicdisorderinorderto
uncoverthecatastrophiccognitionsassociatedwiththese
sensations:perhapsdizzinessmeans 'Iimgoingtofaint'・
Catastrophiccogmtionscanbeelicitedbyencouragingclients
toengageininteroceptiveexposureexerciseslikerunning
onthespot,spinninginachair,hyperventilating,staringat
brightlights, shakingone'sheadfromsidetoside(Barlow
andCraske, 1989) ．Forexample, aclientwhoranonthe
spotfortwominuteswasterrifiedthat 'Myheartisgoing
t6giveoutifldon'tstopnowltcan'ttakethestrain! ￨The
client'sNAIbarerevealedthroughthisexercise;priortoit,
thetherapistascertainedfromtheclient'sGPthat the
clienthadnogenuineheartproblems.
41
之①垣里どの涯昌◎ヨ豊胃﹃寺︒直垣ミ鋤
stimulate further introspection lsearchingthemindfor
moreNAIblontheclient!spart.Additionally,whenthe
therapistputsforwardsuggestions, sheisemphasizingto
herdientsthatshemaybewrongandit isokaytobe
BehaviouralTasks
Situationalandinteroceptivee"osureexercisesdescribed
aboveareaimedatuncoveringhotcognitionsusuallyrelated
toanxietyandpanic!behaviouraltaskscanbeusedwithany
problemtouncoverdistressingthoughts. Forexample, a
clientwhokeptputtingoffphoninghismother- '1'mnot
surewhy' -wasaskedbythetherapisttomakethephone
callduringthesessionltheclientagreedtodothis).Afterthe
一両仁の冒乏町ミ塞旦殉﹄①塁ト①堂蓬巨ｑＯＱ
phonecall, theclientsaiditwasclearwhyheavoidedphoninghismother:'Icanitstandlisteningtohernon-stopmoaningandcomplaming・Shehasn'tgotagoodwordforanyone.
Shedrivesmearoundthebend'.Additionally)hefeltgunty
forhavingsuchthoughts: ｣Ishouldn'tthinklikethatabolil
mymother. I1mabadsonfordoingso.!Hehadadouble
doseofNAIb;duringthephonecallandtheguilt‑related
thoughtsheexperiencedafterwards.
SuggestingaThoughtThatis
OppositeTbaClient'sExpected
Response(Beck,1995)
Thismeansstimulatingaclient'scognitiveawarenessby
suggestingtheoppositethoughttotheonethetherapist
believesisactuallyimplicatedinhisproblemsandhehas
difficultypinpointing:
777elapjsf; Ybu'reanxiousaboutgoingtothepartythisweekend
andyou'renotsurewhy[clenmodq.Areyouanxious
aboutbeingthecentreofattentionallevening,everyone
wantstotalktoVou？
C"enr;
[s/7akmg/7/S/7eadl lfonly…no,what i'manxious
about isbeingaloneaileveningbecausenoonewill
beinterestedintalkingtome.
7he垣p/Sr：
Because． . .？
C//enr:
Peoplewill thinkl'mboringandkeeptheirdistance.
[777ec"enrjsnowc/earwhy/1e/Sanx/o"sabo"#go/ngro"7epart)z]
42
DistinguishingNAIS
FromOtherThoughts
Clientsmayproduceastreamofthoughts!manyofwhich
areperipheralorirrelevanttotheiremotionalproblems.
Thetherapistwillneedtosiftthroughthiscognitiveoutpouringinordertopinpointhot lemotionallychargedl
thoughtsratherthanrespondtoeverythoughtverbalized
bytheclient.Forexample,aclientwhofeelshurtthather
partnerforgotanimportantanniVersarysays: 'Itwasthe
firsttimewemet・Werememberiteveryyearbygoingout
inordertorevealhotones: 'Whatdoesitmeantoyouthat
yourpartnerdidn'tbotherthisyearcelebratingyourwhen‑
we‑first‑metanniversary?'Theclientreplies: 'Hedoesn't
lovemeanymore・ Ithoughtourlovewouldendure. IIve
donenothingtomakehimstoplovingme.Whyishetreat‑
ingmelikesthis?'andstartstocry.2
SomeclientsconfuseNAIbwithsituations, forexample!
aclientsaysthatherboyfriendnotphoninghermadeher
depressed. Inactuality｢herboyfriendnotphoningheris
thesituationandthemeaningsheattachestothesituation
(whichiscurrentlymissing) leadstoherdepression.The
meaningisrevealedas: 'He'sgoneoffme.He'sdumped
meforsomeoneelse. Ican'tbehappywithouthim'.
Anotherclientmightsay,'1'manxiousbecauselmightnot
getthejob',andassumethisisakeyNAT"Thisisnota
negative, distortedthoughtbutarealisticappraisalofthe
situation.Theclient'sthoughtwouldbethesituationlthink‑
mgaboutthepossibilityofnotgettmgthejobland,again, the
meaningtheclientattachestonotgettingthejobproduces
theanxiety. Inthiscase: 'I'1lnevergetagoodjobbecause
43
三⑩廻豊言①連一再Ｏヨ豊苛︒５戸喧弓訂
forameal.Hedidn'tbotherthisyear.Forgotallaboutit.
Heknowsit's importanttomeandl thoughttohimas
well・Obviouslynot，Well，what'sgoingtohappennext？
Whatnewsurpriseshashegotinstoreforme?'
Thetherapistneedsto'cutinto' thesenot‑so‑hotthoughts
peoplethinkl'mincompetent'.Itishotthoughtsthatare
requiredfromclients｢notthoughtspe7se.
DailyThoughtRecord
Onceaclient'sNAIbhavebeenelicited, theycanbewritten
downonaforminorderforhertogainanobjectiveper‑
spectiveinexaminingthem・Theformforthispurposeis
theDailyThoughtRecordIDTRIwhichhelps'clientstodis‑
tinguishbetweensituations, thoughtsandfeelings {ABC
modell, identifyinaccuratethinking,anddevelopmoreaccu‑
rateappraisals' ITinchandFriedberg' 1996: 1) .TheDTR
一司廷２コ三吋ミ当Ｑ哩曾産①ミ廷巨匂︒︒
comprisesafivecolumnworksheet IseeFigure3･lOnp.46).3
1ntheearlystagesoftherapyjclientsaretaughttofillinthe
firstthreecolumnstogainpracticeindetectingNAIband
seeingtheirlinktoupsettingfeelings. It isimportantfor
clientstorateontheDTRthebelievabilityoftheirsituation‑
specificNAIblonascaleofO‑100percentlandtheintensity
oftheiremotionalreactionstothesethoughts(0‑100percent)
inordertodetermineiftheyareworthclinicalinvestigation‑
lowscoreswouldindicatenot・Thecut‑offpointforinvesti‑
gationcanbedecidedcollaborativelylsay,thoughtsand/or
feelingsbelow50percentl.
Distinguishingbetweenthoughtsandfeelingsisvital in
CTifclientsaretounderstandthepowerfulimpactthat
theformerhaVeonthelatter･ Saying '1feel…′ doesnot
alwaysmeanclientsaree"ressingfeelings, forexample,
'Ifeelthateveryonedislikesme'or '1feelthatmywifeis
Iosinginterestinme'. InCTterms, thesearethoughtsnot
feelings.GreenbergerandPadeskysuggestthat 'asagen‑
eralrule,moodscanbeidentifiedinonedescriptiveword
[anxiety,depression￨ anger, guilt,hurt, shame]. Ifittakes
youmorethanonewordtodescribeamood,youmaybe
describingathought' ￨1995:28).
Thetherapisthelpsherclientstoconverttheir '1feel .. .
[thinkl' statementsintogenume 'Ifeel…' stateInents. For
44
example,ifachentsays'1feelthatnothmgevergoesrightfor
me'! thetherapistrestructuresthisstatementbysaying,'Ybu
believethatnothingevergoesrightforyou,howdoyoufeel
giventhatbelief?' Ifthetherapistdoesnothelpherclientsto
makethisconversion,theymaybehevethatsheischallengmg
theirfeelingswhen/ infact,sheischallengingtheirthoughts.
ElicitingJohn'sNATS
Johnistheclientwearefonowingthroughthisbookwhohas
discretesocialphobia.John'sNAIbwereelicitedintheinitialassessmentashefoundthemeasytodetect.Hereadily
understoodseparatinghisproblemintosituation,thoughts
John:
[w"伽gonf/7elbrm]Thesituationwas#Waitingforthe
minutesofthe lastmeetingtobepassedtomefor
signing' . Iwasfeelingveryanxious.
[Encol"agej/ourc"enisro"o"ｵ〃7eDTR, ﾉa"7er"7ando/ng〃わr
fhem. 7 heessenceofCTIS/7e""7gc//enisfoheゆめemse/ves.]
7 he煩p/St：
Joh":
777elapbr:
Whatwastheintensityoftheanxiety？
Iwouldsayashighas90percent.
Whatwerethethoughtsrunningthroughyourmindin
thissituaMontomakeyoufeelsoanxlous？P￨easerate
thebelievabilityofthethoughtsatthetimetheyoccurred.
Jo/7":
Mythoughtswere(Myhandwillshakeuncontrollably'
and:l'llbeseenasnervousandoutofcontrol'.igive
7 heﾉap/Sr：
John:
90percenttobothofthose.
Anyothe『thoughts？
Ohyes. !Mycredibilitywill bedestroyed'whichgets
a95percentand:Theywon'twantmeaschairman'
which is90percent.Thosearelhemainthoughts
lhadinthatsituation.
7 heﾉap/sf:
Okay.Thanksforfi llingoutthefirstthreecolumnsof
theDTR.Thenextstep isforyoutoanswerthose
thoughts.
45
芝の堕豊言のヱミ◎ヨ豊胃﹃ず︒直ロミの
andfeelingsontheDTRform(seeFigure3.1):
lastmeetingto
bepassedtome
forsigning
minutesofthe
aschairman
90%
95%
Mycredibilitywillbe
destroyed
Theywon'twantme
90%
90%
andoutofcontrol
￨'llbeseenasnervous
Myhandwillshake
uncontrollably
宮
Anxietv
90%
0%‑100%
0%‑100%
Waitingforthe
Ratebelievability
ofaltemative
Rateintensity
ofemotions
Ratebelievability
ofthoughts
thOughtsO%‑100%
0%‑100%
ofemotions
Re‑rateintensity
Now？
BalancedThoughts
Describeclearly
andconcisely
HowDoYouFeel
AIternativeand
Emotions
NegativeAutomatic
Thoughts
DaiIvThouqhtRecord ｛DTRb
~
Separatingsituations,thoughtsandemotions:John'sDTR
Situation
Figure3o1
ExaminingNA1S
Thetherapist'smajortaskistohelpthepatient think
ofreasonableresponsestohisnegativecognitions...to
differentiatebetweenarealisticaccountingofeventsand
anaccountingdistortedbyidiosyncraticIpersonal]meamng.
(Becketa1., 1979: 1641
isbasedoncollaborationwherebythetherapistandher
clientactasateamusingreasonandreality‑testingtocon‑
structnewwaysoflookingatoldproblems. Sometech‑
niquesforexaminingNAIbarenowdescribed.
WeighingtheEvidence
This is themost commonmethodfOrestablishingthe
relativetruthorfalsityofaparticularthought(s).Weuse
theword'relative'becausesomeNAIbcontainelementsof
truth, forexample,aclientsaysnoonelikeshimandwhen
theevidenceforthisassertionisexamined, itturnsoutthat
somepeopledonotlikehimltheNATwaspartlytrue)!
somedolikehimandothersareindifferenttohim・When
47
之①○ｍ壁くい淫筐冒ヨ凹萱︒﹃ず︒Ｅ垣︒蕨
Byencouragingyourclientstogeneratemoreadaptiveand
balancedresponsestotheirnegativethinking, thisdecreases
theintensityoftheirdistressingfeelingsandreleasesmore
timeandenergyforimprovedproblem-solving. Inorderto
achievethisoutcome,clientsaretaughttoregardtheirmaladaptivethoughtsashypothesesratherthanasfactsabout
themselves, others andtheworld. Seeing thoughtsas
hypothesesallowsclientstotestthesethoughtsandreachdifferentandmorehelpfulconclusionsaboutthemselvesand
theirproblems. Iftheclient'sNAIbareseenbyhinlasincontrovertiblefacts ('1'llalwaysbelonely;That'smyfate')! then
thereisli廿lechanceofconstructivechangeonhispart.
Examiningclients'NAIbisnotaboutPrOvingthatyour
viewpointisrightorattackingtheirthinking.Examination
youexaminetheevidence,donotattempttomanipulateit
inordertomanoeuvreyourclientintogivingthe 'correct'
answerthatyouwanttohearlyouwillnotbeagoodrole
modelforopen-mindednessifyoubehavelikethisl.
ConstructingAIternative
ExplanationsforEvents
BlackburnandDavidsonstatethat
F
冊
orexample,aclientwhostatedthat 'myopinionisunimportant'becauseherbossdidnotaskforitatameeting,
listedthesealternativee"lanations:
盤
Ⅲ
１
２
堂のこの胃三町ミ語旦図輿匡の員建巨画︒︒
askingthepatienttolistalternativeinterpretationsofa
situationandthenesmblishi"rﾉze7eqlisiicp7obqbi"ofeach
interpretationisapowerfultechnique,asitdoesnotreject
theoriginalnegativeinterpretation,unlikelyasitmightbe｢
andcontrastsitwithmorelikelyintelpretations.11995:76;
italicsinoriginal)
︑ｄ刈牛
'Hewasangrywithme'.
Heforgottoaskme'.
'Hehatesme'.
５
６
'Healreadyknewmyopinionbecauseltoldhimbefore
themeeting'.
IHe'splanmngtodemoteme',
IHetriedtohumiliatemeinfrontoftheothers'.
Theclient,afterexaminingeachalternative,concludedthat
themostrealisticprobabilitywasnumber4.Atthenext
session,shesaidthatnumber4wasindeedcorrectbecause
herbosshadconfirmeditwhensheaskedhim(shesaidit
wouldhavepreventedherfeelingupsetifshehadasked
himstraightafterthemeetinginsteadofjumpingtoconclusionsduringit).
48
AdvantagesandDisadvantages
Thistechniquehelpsclientstoteaseouttheadvantagesand
disadvantagesofkeepingormodifyingaparticularthought
Iforexample,'Imustalwayspleasepeople"lorspecificbehaviourIsay!workinglonghours).Wellssuggeststhat
aneffortshouldbemadetogeneratemoredisadvantages
thanadvantages…whenthedisadvantagesofmaintainingabehaviourorattitudeoutweightheadvantages, the
individualshouldbemoremotivatedtochange.|1997:72)
ldentifyingCognitiveDistortions
Decatastrophizing
This involves clients developing copmg strategles to
countertheircatastrophicthinking Catastrophicthinking
49
電︒﹃寺︒匡垣ご蹄
WelistedsomecognitivedistortionsinChapterl llabelling'
forexamplel.Providingclientswithalistoftypicalcognitivedistortionscanhelpthemtoidentifytheirown,suchas:
'Whenl'manxious, Istarttoreadpeople'sminds.Things
like "Shethinksl'mboring"or"Hethinksl'mstupid". I
knowit'ssilly, butlcan'tseemtostopmyselfdoingit'.
Withmindreading,weemphasizetoourclientstoread
theirownmindsinsteadofotherpeople'sandreadtheir
ownminds inanon-distortedway(NeenanandDryden!
2002al.Intheaboveexample,whatobjectiveevidencedoes
theclienthavethatpeoplethinkaboutherinthiswaylher
evidenceisusuallyaprqjectionontoothersofherown
beliefsl？IfsomepeoPledoseeherinthisway1shestillhas
thechoiceofwhetherornottoagreewiththem.
之①い︑雪く⑩姿こざヨ
Intheaboveexamples, thefirstclientsees'peoplepleasing'
asmoreexhaustingthansatisfyingwhilethesecondclient
viewslonghoursasdetrimentalto 'ahappyhomelife
whichisveryimportanttome'.
isoftengeneratedby'Whatif".' speculationswhichcan
beansweredby'Thenwhat...'determinationtodealwith
oneisworstfears:
Whatifmypartneris
havinganaffair？
ThenlwillconfronthimabOutit
Whatifheleavesme？
Thenlcanlearntobemore
Whatiflcan!tcoDe
L
onmyown？
independent.
Thenlcouldseekhelptocope
withit. It'snotlivingalonethat
istheproblembutmyscary
attitudetoit.
一両この旨三田Ｅ語Ｑ殉﹄の塁ト①ミ蓬喧画○○
Whatiflnevermeet
Thenthatwouldbeableakfuture
anyoneelse？
butitIshighlyunlikelyunless
Istayineverynightfortherest
ofmylife.
Reattribution
Reattributionhelpsclientstostepbackandconsideranthe
factorsthatcontributedtoanadverseoutcome.Forexample,
aclientfeelsguiltybecauseheblameshimselfforhisfamily's
'disastrousholiday'.However'heoverlooksthemanyfactors
thatwereoutsideofhiscontrolsuchasHightdelays,poor
accommodation, foulweather!dirtyswimmingpools,rowdy
tourists,dirtybeaches,unpalatablefood.Reattributionisnot
meanttoletclients 'offthehook' iftheyareresponsiblein
somemeasureforaparticularnegativeoutcome,butencouragesthemtoconsideriftheyarewhoUytoblameforit lin
theaboveexample, theclientsaidthathisportionofresponsibihtyfortheholidaywas 'takingthefirstbucketshopoffer
ratherthanshoppingaroundforabetterdeal').
ExploringDoubleStandards
Thistechniquediscoverswhythoseclientswhocondemn
themselvesforhavingaparticularproblemshowsympathyto
50
others Iperhapsagoodfriendl iftheye"eriencedasimilar
problem.Forexample,aclientwhowassupportivetowards
acolleaguewhowassufferingfromstresscondemnedhimselfas 'weakandspineless'whenhetooktimeoffwork
for thesameproblem・ Thedoublestandardtheclient
employedwas: 'Prolongedstressaffectsnearlyeveryone
eventuallybut1 inmycase, Ishouldbeabletodealwithit
becausel'mastrongpersonandthereforeshouldnitfall
aparti.Byhelpingtheclienttoshowthesamecompassion
tohimselfashedidtowardshiscolleaguelandrevisinghis
assumptionsofwhatconstitutes 'astrongperson' ￨,hewas
abletoditchhisdoublestandardandreplaceitwithareal‑
isticandhelpfulsingleone IBurns, 19891.
Thisprocessconcentratesclients'mindsontheimprecisionoftheirlanguageindescribingthemselvesortheir
problems, forexample, 'Whenyoucallyourself"afailure"，
doyoumeanthatyouareafailureasapersonorthatyour
behaviourfanedonaspecificoccasion?'Clientsusuallyreply
thattheyseethemselvesasafailurewhich, iftrue,would
meanthattheyfailateverysinglethingtheyattempt lthen
howdidtheymanagetogetdressedorcometotherapyon
time?) .Helpingclientstobepreciseintheiruseofterms
('Mybehaviourmayhavefailedbutl'mneverafailure' )
enablesthemtoavoidmakingglobal!negativejudgements
andfocusestheirattentiononwhatcanbelearntfrom
theirsetbacksandfailures.
BehaviouraIExperiments
Theseareusedtotest thevaliditVofclients'NAIband
assumptions.Behaviouralexperilnentsareusedtopromote
cognitivechange.Forexample,aclientpredictedshecould
not 'toleratetheemotionalanguish' ofdiscussingasensi‑
tiveissue.Thetherapistsuggested,asanexperiment｢ that
51
菫の垣勉曇く⑩退こさヨ凹電︒﹃ゴ︒こいご厨
DefiningTerms
theclientcouldtalkabouttheissueforfiverninutesand
菫些宙凸コミ妃ミ語旦飼芯舞岸⑩崖﹄ミロ◎︒
thenstoptoassessherlevelofdistress: !Shallwestopor
tryanotherfiveminutes?'Throughthismethod, theclient
wasabletousethewholesessiontoaddressherproblems
becauseshecould, infact, tolerateexperiencingemotional
anguiShwhiletalkingaboutthem.
Ybuneedtobeawarethatasuccessfulbehaviourale"erimentdoesnotautomaticallymeancorrespondingcognitivechange. Intheaboveexample, theclientmayhave
concludedthatshecouldonlytolerateemotionalanguish
becauseshehadthesupportofthetherapist. Ifthiswasthe
case, thenanappropriatehomeworktaskwouldbeforher
tothinkaboutandmakesnotesonherproblemswhenshe
isalone.
SocraticQuestioning
(GuidedDiscovery)
AswenasehcitmgNAIb,Socraticquestioningisalsoemployed
tohelpclients 'openup' theirclosed-mindedandproblemperpetuatingthinking.AsBecketql.observe:
QUestioningleadspatientstogenerateoptionsandsolutions
thattheyhavenotconsidered…thisapproachputspatients
inthe 'questiomngmode' (asopposedtothe 'automatic
impulse'mode) sothat theywill start toevaluatemore
objectivelytheirvariousattitudesandbehefs. (1993:291
Forexample,aclientwhocomplainsthatherpartnerfrequentlycalls'mestupidandthisreallyupsetsme',isguided
bythetherapisttoexamineherthoughtsanddevelopalternativeresponsestoherpartner'sput-downs:
C//e"r:
ldon'tknowhowelsetorespond.
777erap/Sr
Well, let'sthinkabout itnow.Doyouagreewithhim
q~
thatyouarestupid？
52
C"eni
I'mnotsure. ￨meanhe'sbettereducatedthanme・He
wenttouniversityandldidn't,soIsometimeswonder
iflamstupid.1havesofewqualifications.Isupposeto
thatextentldoagreewithhim.lneverthoughtabout
itbeforeinthatway.
777elap/sf
C//enf:
777eﾉapﾉSt
C"enr:
C//ent
777elap/si
name‑cal linq？
シ
C"enf:
l thinksobecauselwanttostopagreeingwithhim‑
￨ seeitsoclearlynowwhat l keepdoing‑andstart
standingupformyself. lt'snot justname‑calling l've
gottoputupwith.
[7 hec"eﾉ7r"7[力℃aresihafo"7era/easof ihe尼個"ons/7"need
a"Jess/ngioo.1
Socraticquestioning,asintheabovedialogue,isofteneffec‑
tivebecause it 'canhelpaclientdevelopanalternative
perSpectivethattheclientfindscrediblebecauseitisbased
oninformationprovidedbytheclient,notthetherapist'
(EdeskyandGreenberger,1995: 11).
53
三のい︑ミミ⑩垂匡旨ヨ凰苛﹃ゴ︒戸喧．厨
7 heﾉap/sr
Canpeoplestill considerthemselves intelligenteven
if theydidn'tgotouniversityorhavefewacademic
qualifications？
Ofcoursetheycan.
￨nwhatwaycanthey？
Well, intelligenceis…ismuchwiderthanjustacademic
qualificationsorgoingtouniversity. 1'mnotsurehowto
putitbutlknowwhatlmean.
Soinwhatareasofyour lifeareyou intelligentusing
yourwiderunderstandingof intelligence？
Well, Isupposel 'mmuchmorepractical‑mindedthan
he is: 1 1ookaftertherunningof thehouse, get the
repairsdoneordothemmyself−he'shopelesswhen
itcomestoDIYforexample. 1f ldidn't looka廿erthings,
thehousewouldfalldownaroundhisears.Isuppose
ifhecallsmestupid, lcancallhimstupidback.He's
gothisformofbrainsandi'vegotmine.
Doyouthinkyoumightbelesssusceptiblenowtohis
ExaminingJohn'sAutomatic
Thoughts
Aswedescribedearlier inthischapter, thefirst three
columnsoftheDTRareusedforrecordinganddistinguishingbetweensituations/ thoughtsandfeelings.Throughthe
■
一両垣２．之殉ミ至旦侭句塁トの堂﹄ミロ︒︒
processofexaminingNAIb,clientsanswerthemincolumn
fourwithmorebalancedresponseswhich,inturn,reduce
theintensityoftheirdistressingfeelingsincolumnfiveIsee
Figure3.2).Theseresponsesshouldbebasedonacareful
evaluationoftheevidenceforandagainstaparticularNAI)
notonthefirstresponsetheclientuttersasthismightbe
unrealistic,overlypositiveorevenmoreunhelpfUlormaladaptivethantheNATitself.
TbreturntoourclientJohnwithsocialphobia,hisanxiousthoughtshavesofarbeenelicitedandrecordedonthe
DTR;thenextstepisforhimtogenerateresponsestothese
thoughtswiththehelpofthetherapist:
Thelapjsr
Jo/7n:
777elap/Sr
Nowyourfirstthought is$Myhandwillshakeuncontroliably'.We've lookedat someways toevaluate
automaticthoughts, sowhat istheevidenceforthis
particuIarthought？
Myhandhasshaken...
Uncontrollably？
Jo/7n:
No,neverthat.
刀7erapﾉSf
Sowhat responsewouldyouliketowriteontheform
aIongwithapercentageratingfor itsbelievability？
[w"imgo"r/7eDTR] $lthasshaken inthepastbut
neveruncontrollably'andl'llgivethat70percent.
Jo/7，
[Johnb/7andS/7akmguncomo"ablyw///beaddrPssed値rer/nf/7eF
apyasparrofawoﾉsrcasescena"ocoPﾉng/esponse"]
7 he/apjSr:
Thenextthought is(1'llbeseenasnervousandoutof
control,．
54
当
lastmeetingto
bepassedto
meforsigning
minutesofthe
90%
ゞ
and,asfarasIknow,they
stillwantme
Theyvotedmechairman
chairman
90％
Theywon'twantmeas
75％
seriousthanmyhandshaking
formycredibilitytobe
destroyed
75%
95%
deStroyed
70％
ltwill takesomethinqfarmore
thenl ' ￨ ￨askthem
Mvcredibilitvwil lbe
90％
I!mmindreadingagain. lf lwant
lthasshakeninthepastbut
neveruncontrollably
70%
toknowhowtheVreallVseeme,
90%
￨，￨￨beseenasnervous
Anxiety
thoughtsO%‑100%
O％−100％
andoutofcontrol
Myhandwillshake
uncontrollably
O％‑100％
Ratebelievability
ofalternative
Anxiety
0％−100％
40%
ofemotiOns
Re‑rateintenSity
FeeINow？
BalancedThoughts
Rateintensity
Ratebelievability
ofthoughts
HowDoWu
AItemativeand
ofemotions
Emotions
NegativeAutomatic
Thoughts
John'scompletedDTR
Waitinqforthe
clearlyand
concisely
D噂gcribe
Situation
Figure3.2
Jo/7n:
lknowl'materriblemindreaderinthissituation.
刀7elapﾉSr
Haveyouactuallyaskedanyofthecommi廿eemembers
howyoucomeacrossasachairman？
Isupposel'mreluctanttoincaselhearwhatldon't
JO/7"
wanttohearbut,ontheotherhand,ldon'twant to
keeptorturingmyselfwiththismindreading.
刀7elap/sr
Sowhat'syourresponsethen？
Jo/7n:
￨'II say!I'mmindreadingagain', Iwill takesoundings
amongthecommitteememberssoI'llput !lf lwantto
knowhowtheyreallyseeme, thenl'llaskthem'andl ' ll
givethat70percent.
Thenext thought is@Mycredibil itywill bedestroyed'
andyougavethatyourhighestbelievabilityrating.
￨mustgivetheimpressiontoyouthat l beiievethey
areavindictiveandmean‑mindedbunchwhenthey
arenotthatwayatall,apartfromafewoccasionalper‑
sonalityclashes, iknowmyfearsarenotrealistic.
Soiftheyarenotrealistic,howwillyourespondtothat
thought？
{ ltwill takesomethingfarmoreseriousthanmyhand
shakingformycredibilitytobedestroyed'andl' ￨￨give
that75percent.
AndthelastthoughtontheDTRis;Theywon'twant
刀7eﾉap/sr
一芯︽窃曽之応昌語旦廻凹仁聖篭這句︒︒
Jo/7n
777elapﾉSr
John
777e/ap/sr
measchairman' .
Jo/7n:
7 hejap/st
Theycertainlyarenotgoingtovotemeoutaschair‑
manjustbecausemyhandshakesTheyaremore
toleranttomethan lamtomyself, so l ' llwrite!They
votedmechairmanand, asfaras I know, theystill
wantme'andl'llgivethat75percent｡
￨fweturntocolumnfiveontheDTR,withthose
alternativethoughts inmind, howwouldyounow
ratetheintensityofyouranxietywhenyou'reinthe
John
spotlight？
lt'sdroppedconsiderably,downto40percent. l can
seehowthinkingdi廿erentiy, andbelieving inthese
newthoughts,canhelpmetofeeldi廿erentlv.
刀7eﾉ召p/sr
Good.
56
Forreasonsofspace, this isacompressedaccountof
thedialoguebetweenJohnandhistherapist.Wedonot
want togivetheimpressionthatgeneratingalternative
responsesisastraightforwardoreasyprocess.Sometimes
thisprocesscanbeverydifficultaswhenclients 'shoot
down'anysuggestionmadebythetherapistorcannotfind
anyevidencethatchallengestheirNATも． YOurpatience
willbetestedinthesecircumstancesbutitisimportantto
persevere inanopen‑minded, non‑defensivewayuntil
somesuggestion, observationorquestionfromyoucan
providethepathwaytoaresponsethattheclientfinally
findscredible.
Notes
1.Whenclientsareaskedtorevealtheirupsettingthoughtsinaspecificsituation, theyarenotawareofthedi付erencesbetweenNATs,
underlyingassumptionsandcorebeliefs;sowhattheyrevealneeds
tobe{sortedthrough'bythetherapist inorder tocategorizethis
cognitivedata.Corebeliefsareusual lyrevealedwhenclientsare
expressinghighnegativeaffect(emotion).
2. Thetherapistwasabletouncovertheclient'shotthoughtsrather
thanstaywiththenot‑so‑hotonesbecauseshewasfollowingthe
cognitivethemespresent inemotional disorders (seecognitive
content‑specificityhypothesisinChapterl). ￨nthiscase, thetheme
inhurtisbeingletdownortreatedbadly(andtheclientbel ievesshe
57
三①廼豊菅①エミさョ豊苛乱ゴ︒こいミ切
Asclientsgaincompetenceandconfidenceinfillingout
theseforms｢ theyusuallyfindtheprocessofidentifying,
challengingandchangingtheirNAIもquickens, thereby
allowingthemtocarryoutthisprocessmentally.TheDTR
canalwaysremainonstandbyifclientsneedto'returnto
basics' fromtimetotime.Thelearningthatoccursinthe
sessionneedstobeintegratedintotheirdailylife.Thisis
achievedbyclientscarryingouthomeworkassignments
whichisthesubjectofthenextchapter.
doesnotdeservetobetreatedinthiswav)whichisreflectedinthe
画〃
client'shotthouqhts.
￥
3
GreenbergerandPadesky(1995)useaseven‑columnDTRwork‑
sheet.Thetwoadditionalcolumns(4and5)areforwritingdownthe
evidenceforandagainsttheclient'shotthoughts. ￨nthefive‑column
worksheet, theevidenceforandagainstthehotthoughtsisdiscussed
ratherthannotedbeforeanaltemativeresponseisformulated
三里万冒之田星当ｑ図①ニト①畠逹巨句︒︒
58
Thetherapysessionisusuallyapoorarenaforassessing
changebecauseofitsremovefromtheclientiseveryday
e"erience.AssignmentscarriedoutbetweensessionsIhomeworkl allowclientstotestandmodifytheirmaladaptive
thoughtsandbeliefsinreal‑lifesituations・Homeworkhelps
clientstolearntheskillsofcognitivetherapyanddevelop
confidenceinbecomingtheirowntherapistwhich,inturn,
reduces thechancesofarelapse lfallingbackintothe
originalproblem).AIso｢withouthomeworkassignments,
clientsmaybecome ｣emotionallyconstipated' (waiting'to
tellitall'atthenextsessionl insteadofdealingwiththe1it'
ldifficulties) as theyarisebetweensessions.AsPersons
observes:
Situationsthatarousepowerfulaffect [emotion]probably
involvethepatientIskeyunderlyingideas'andtheability
toworkonthesewhentheyareactivatedoffersapotent
opportunityforchangethatwouldbemissedifallthera‑
peuticworktookplaceduringtherapysessiOnS.11989: 142)
HomeworkisanessentialpartofaCTtreatmentpro‑
gramme,notanafterthoughtdependingonhowthesession
wentoriftheclient 'isinthemood' todiscusshomework.
Therefore,fromthefirstsessiononwards,clientsshouldbe
encouragedtocarryouthomeworktasksratherthandelay
implementationofthesetasksuntil theyfeelmorecom‑
fortablewiththeCTformat.Therationaleforhomework
ispresentedtotheclientandfeedbackissought;additionally｢
thetherapistcane"laintoherclientsthatresearchindicates
that thoseclientswhocarryouthomeworkmakebetter
progressthanthosewhodonotcarryitout lforexample,
BurnsandAuerbach,19921.Specifichomeworktasksare
discussedandagreedthroughcollaboration, thoughin
theearlystageoftherapythetherapistoftentakesamore
directiveroleinsettingsuchtasks, asclientsareusuallv
uncertainat thisstagewhat taskswouldhelpthemto
二
tackletheirproblems.
HomeworkTasks
ETheseusuallyincludeamixtureofcogmtiveandbehavioural
2 tasksCognitivetasksincludethefollowing:
こ
。
之
殉
.E ・ Readmg.ThereisasubstantialCTself‑helpliteraturethe
語
旦
therapistcanrecommendtoherchents' includingOve7co""
LowSel/zEs花embyMelanieFennellll999),Ove7co77fmg
囚
①
;2
Dep'1ibyPaulbilbert l2000blandbMej･66""gA"xiej
S
｡）
byHelenKennerleyll997).Self‑helpbooksarenotasub‑
stitutefortherapylbutaneducationaladjuncttoit,
stituteforthera
butaneducatlonaladjuncttoit, educat‐
educat‑
O
ingtheclientaboutthefeaturesoftheemotionaldisorder
韓
口
o
sheisexperiencingandtheCTmethodsfortacklingit.'
o
Listening. Clients areencouragedto tape‑record their
sessionsinordertolistentothemathome. Someclients
process information inadequatelyduring the sessions
because, forexample｢ theyareoverlyupsetorfeelembar‑
rassedtoadmittheydonotunderstandthepointsthether‑
apist ismaking.Ontheirown, theseclientsarelikelyto
feel lessdistractedorinhibitedandtherebygaingreater
therapeuticbenefit fromlisteningtothesessioncontent
thantheydidparticipatingintheactualsession.
oWritmg.FillinginDailyThoughtRecords IDTRsIorvaria‑
tionsofthemarethemainwritingactivitiesclientsengage
in.Theseformshelpclientstoノstepback' fromtheirNAIb
60
Inegativeautomaticthoughts) andrespondtothemina
calmerandmorebalancedway.Whenclientsmoveonto
workatdeepercognitivelevels'theycanusedifferentforms
formodifyingtheirunhelpfulassumptionsandnegativecore
beliefs.WritingassignmentscaninvolveanyprOjectthatwill
helpclientstoaddresstheirproblemsmoreeffectively/ for
example,aclientwroteanessayentitled, 1Whyreassuranceseekingispartoftheproblem,notpartofthesolution｢,to
helphertacklehersevereandpersistenthealthanxiety
￨hypochondriasislaboutdevelopingabraintumour.
･ Imagery lthis is includedwithintheterm'cognition').
Clientscanvisualizethemselvescopingwithanadverse
situation:aclientwhoworriesthathewillforgetwhatheis
talkingaboutwhengivingapresentationtohiscolleagues!
Behaviouraltasksinclude
●
Activityschedulmg. This isatechniqueusedwith
depressedclients,particularlyintheearlystagesoftherapy,asithelpsthemtocombattheirmactivity, indecisivenessandrumination・Theclient'sdayisusuallydivided
intohourlysegments (9‑10am! 10‑11am, 11am‑12pm,
andsoon)andisplannedinadvancesohedoesnothave
toworryattheendofeveryhourwhattodointhenext
one.ClientsareaskedtorateonascalefromO‑10hOw
muchpleasureandwhatsenseofaccomplishrnentthey
derivefromeachhourlyactivity・Thisscalehelpsclients
totesttheirofteninaccuratepredictionsthat theywill
note"erienceanypleasureoraccomplishmentfromthe
activities theyundertake. Activityschedulingisakey
behaviouralactivationtechniqueusedinthetreatmentof
depression(Kuehlwein,2002).
61
エ︒ヨのミ︒﹃詩
canbehelpedtochangethedirectionoftheimagetoasuc‑
cessfulsceneofhimselfaskingsomeoneintheaudience
'Whatwasljustsaying?' asaprompttogethistrainof
thoughtbackontrack.
･Gradedtaskassignments.Thesehelpclientstotackle
theirproblemswithsmall,manageablestepsbefore
makmgbiggerstridesofincreasingdifficult)Zforexample,
aclientwithagoraphobiamakes,overthecomingweeks,
short tripsfromherhouseto 'testthewaters' before
goingtoherlocalsupermarketandthenmakingaday
triptoLondon． Someclientsmaysetunrealistically
ambitiousgoalsintheearlystagesoftherapyiinonecase
aclientwhoisveryshyaroundwomenwantsanimme‑
diatetransformationintoa 'ladv'sman' rather than
learningsomesocialskillsinordertoimtiateconversa‑
一
tionswithwomen.Aruleofthumbfortheseclientsto
followinsettinghomeworkgoalsis: 'Startwhereyouare,
E｡，
notwhereyouwanttobe' (Persons, 1989: 1461
1461．
& ･ Experiments.Carryingoutexperimentsallowsclients
仁
コ
:
todeveloptheroleofapersonalscientistwherebythey
oミ
treattheirthoughtsashypothesesandthentestthem;
theresultsoftheexperimentsarediscussed, conclu‑
sionsaredrawnandcomparedwithclients' original
predictions. Forexample, aclientwhopredictedshe
wouldbelaughedatbyherclassmatesifshesaidshe
didnotunderstandapointmadebythetutorfound, to
hersurprise, thatnoonelaughedatherwhensheasked
himforclarification(infact, severalstudentstoldher
afterthelessonthattheydidnotunderstandthepoint
m
語
Q
里
①
筐
の
＞
■＝
■〜
E
動
◎
O
either) .
Theresultsoftheexperimentdisconfirmedherprediction,
but theclientwonderediftheexperiment 'wasafluke'.
Theexperimentwasrepeatedseveraltimeswiththesame
resultsobtained.Iftheclienthadbeenlaughedat, thenthe
meaningsheattachedtoitl'Thisproveslmustbestupid' )
wouldneedtobechangedsoanyfuturelaughterwouldbe
renderedharmlessinhermindle.g. 'Therealstupidityis
notaskingwhenldon'tunderstand,soletthemhaVetheir
funwhilelconcentrateonlearning').
62
TheRationaleforHomework
Theimportanceofhomeworkwasdiscussedatthebeginning
of thischapter! andthis importanceshouldbeclearly
communicatedtoyourclients.AsBlackburnandDavidson
remark:
Homeworkfulfilstwofunctions: first, itcreatesalink
betweensessionsensuringthatthepatientcontinuesto
workonhisproblems; secondlyi itenableshimtocollect
datatoverifysomeerroneousinterpretationorassumption, totestoutpredictionsortoexperimentwithnew
behaviours.11995:541
iWin-Win'FormuiaofHomework
Thismeansthatwhateverhappenswiththehomework
task-completed,attempted, alteredoravoided-importantinformationwillbegainedandevaluated.Forexample,
adepressedclientwhocompletedherhomeworktaskdismisseditbysaying,'What'sthebigdealaboutdoingsomethingl'vealwaysbeenabletodo?'However,theclientwas
helpedtoseethat shewascomparingherpresentstate
unfavourablywithherpast,non-depressedandactivestate.
Onreflection, andwithmorecompassionforherself, she
realized'Ididokayinpushingmyselftodothetaskeven
thoughl felt lowandunmotivatedI.Homeworktasks
shouldnotbeconstructedintermsofsuccessorfailure
butwhatleq77zi"gcantheclientextract,withthetherapist's
helP,fromthehomeworkassignment.
63
エ◎ヨ①言︒﹃詩
Homeworksetting isbasedonnegotiation, not therapist
diktat(inotherwords,whattheclientispreparedtodorather
thanbeingtoldwhattodobythetherapistl.Homeworkcomplianceismorelikelytooccuriftheclientunderstandsboth
therationaleforhomeworkingeneralandhowcarryingout
aseriesofspecifictaskswillfurtherhistherapeuticprogress.
MakingHomeworkRelevantto
WorkDoneintheSession
Homeworkassignmentsshouldflownaturallyfromthe
workdoneinthesession.Forexample, ifthetherapisthas
emphasizedtheimportanceofbehaviouraltasksthenshe
shouldnotnegotiateacognitiveonesuchasreading; ifshe
hasbeendiscussinganexposureprogrammetofaceone's
fearsthensheshouldnotsuggestdistractionmethodsto
avoidthem.Thetherapistshouldaskherself: 'Isthistask
thelogicaloutcomeof thesessionwork?' Ifherclient
cannotseehowthehomeworkisconnectedtothesession｢
ご曾司冒之応ミ語Ｑ何司曇トの二這匡句︒︒
thenfurtherdiscussionisrequiredtohelphimseethis
connectionor/ ifthisdiscussionisunproductive,anewand
moreclient‑relevanthomeworktaskisrequired.
SpecificityinHomework
Negotiation
Thismeansencouragingclientstostatewhen,whereand
howoftentheywillcarryouttheagreedtask, forexample,
aclientwithliftphobiaagreestoget intoaliftatwork
twicedailystartingonMonday・ Suchspecificityremoves
clientvaguenessabouttheirhomeworkl'I'llhaveabashat
itsometimenextweek' landmakesitmorelikelvthatthev
冬
ユ
willactuallydothetask.
StartingHomeworkintheSession
(Beck,1995)
Duringtheearlystagesoftherapy/ startinghomeworkin
thesessionProvidestheincentiveforclientstocontinueit
outsideofthesession.Beckobservesthat 'patientsoften
describethehardestpartofdoinghomeworkasthePeriod
justbe/b7etheystartit‑thatis,motivatingthemselvesto
getstarted' {1995! 256; italicsinoriginal) .Forexample, a
clientwhowasprocrastinatingoverwritinganessayfor
64
college,agreedtostartitinthesessionwhichthencreated
themomentumforhertocontinueitathome.Thoughts
fuellingherprocrastinationwere identified ('Ihave to
finishitinonegoandwithoutmakinganymistakes')and
tackledltheclientagreedtowritetheessayinroughdraft
stagesandrevisethemlater).Cognitiveand/orbehavioural
assignmentsaremorelikelytobecompletedifdifficulties
withthemarepinpointedandtackledinthesession.
TroubleshootingObstaclesto
HomeworkCompletion
Onceclientshaveunderstoodandagreedwiththerationale
forcarryingout theirhomeworktasksandhavestated
when,whereandhowoftentheywilldothem, thenext
identifiedbutalsotackled.Forexample, aclientsayshe
mightnotbeabletofindthetimeforhOmework:
777elap/si
Whichfamouspersonwouldyouliketomeetmost？
Cﾉﾉenf：
NelsonMandela.
7 heﾉaO/Sr
Wouldvoufindthetimetomeethiminthenextseven
l
寺
daysiftheopportunityarose？
C"eni:
Ls.VerVmuchso｡
771e/apisr
C//enr:
Unfortunately, hewon'tbecomingbutthetimeyou've
putasideforhimcannowbespentdoingthehomework.
Okay,pointtaken.Thetimeisthereif Iwant ittobe.
The/ap/Sf
Nomatterhowmuchpleasureyougetfrommeeting
himitprobablywouldn'tmakemuchofapositiveimpact
onyourpanicattacks,whereasacognitivetherapy
programmeof proveneffectiveness ismuchmore
l ikelytohelpyou ifyougiveitachance.
C"enr
￨,lldoihehomework．
TifoubleshootingislikethetherapistaCtingasa'cognitive
cop' ,apprehendingandmodifyinganyclientthoughtsthat
65
エ◎ヨ⑩署○﹃詩
stepforthetherapististoidentifyanypotentialoractual
obstaclestocarryingoutthehomework.BIocksarenotonly
interferewithhomeworkcompletion(NeenanandDryden,
2002a).
TakeAdequateTimeFor
HomeworkNegotiation
Wehopethatinthischapterwehavemadeitclearthat
homeworkisanintegralpartofaCTtreatmentprogramme,
notanoptionalextradependingonthetimeavailableatthe
endofasession.Therefore, itisimportantthatthetherapistmakesadequateprovisionforhomeworksettingand
theinitiationofthetaskinthestructureofthesession一芯この胃三ｍＥ語旦駒司塁ト①こ﹄這句︒︒
perhapslOorl5minutes,orevenlongerfornovicetherapists. Ifaclinicallysuitabletaskhasemergedearlierinthe
sessionandbeenagreedupon, thenobviouslylesstimeis
neededattheendofthesessiontodiscussitagain､Always
ensurethatyougiveyourclientsawrittencopyofthe
homeworktaskasthisremindsthemofwhat theyhave
agreedtodoIseeFigure4"1onp.681.
TheNon-LinearModelofChange
It is importanttopointouttoclientsthatchangedoes
notmeantheeradicationoftheirproblemsbut,rather,that
theseproblemshavebecomemoremanageableandless
disruptiveintheirlives.Fromthisperspective, changeis
viewedinrelative,notabsolutetermsIsay,occasional,mild
andshort-livedpanicattackshavereplacedfrequent,intense
andlonger-livedones).Changecanbemeasuredalongthe
followingthreedimensions:
・
Frequency‑istheproblemexperiencedlessfrequently
thanbefore？
・
Intensity‑istheproblemexperiencedlessintensely
thanbefore？
・Duration−doestheproblemlastforshorterperiods？
66
AssessingClients'Progress
Clientscanbecomedisillusionedbecauseoftheirperceived
lackofprogressIIImightaswellgiveupNothmgishappening'l.Bysettingclearlydefinedgoalsattheoutsetoftherapy, theycanbeusedasbenchmarksforassessingclients'
Progress: 'OneofyOurgoalswastobeabletogoshopping
inthehighstreetonyourown.Atthestartoftherapylyou
werehousebound.Atthepresenttimeノyoucangettothe
cornershoponyourown{cIie"t"odsl. Inwhatwaydoes
thisachievementrepresentnoprogressonyourpart?'Such
reminderscanhelptocombatclients'pessimismabouttheir
apparentlackofprogressI'Isupposelammakingprogress
butldidn'tthinkitwouldtakethislongorbesohard')and
therebyencouragethemtostayintherapylongertoachieve
theiroriginalgoals.
Johnistheclientwithdiscretesocialphobiawhoseprogress
intherapywearefollowinginthisbook.InChapter2,his
treatmentplanwasoutlined:
1
ワ
臼
3
4
5
ModifyingkeyNAIbandunderlyingbeliefssuchasreplacingself-condemnation('1'mweakbecauselcan'tcontrol
mynervousness')withself-acceptance.
Deliberatelyshakinghishandinordertoexposehimself
tohisfearofpublicderisionforrevealinghis ｣weakness'・
Droppinghissafetybehaviourssuchassigninghisname
veryquicklyonthelastmeeting'sminutesinorderto'get
outofthespotlight'．
Learningprogressivemusclerelaxationtoreducethephysi‑
calsymptomsofanxietythatinterferewithhisperformance.
Gainingaccurateinformationfromothersregardinghis
performanceratherthanrelyingonhowhefeelsinternally
('anervouswreck'ltoguidehisperceptionofhowhe
believesheisbeingseenbyothers.
67
エ◎ヨのミ︒﹃●蚕
John'sHomeworklasks
John!sfirsthomeworktask, agreedattheendofthefirst
■
菫のこい旨三町Ｅ語Ｑ図①塁トのミ蓬こ画︒︒
session,wastostartlearningprogressivemusclerelaxation
IPMR).2APMRaudiotapewas suppliedtotheclient.
Additionally,heagreedtoelicitandrespondtohisNAIbon
theDTRformashehaddoneinthesession.Duringthe
secondsession, therapistandclientdiscussedhowthe
latter'ssafetybehavioursactuallyhelpedhimtomaintain
hissocialphobiabypreventinghimfromtestinghiscatastrophicpredictionthathishandwouldshakeuncontrollablyifhedidnotkeepitandhimselfundertightcontrol
whenhewaUinthespotlight'atameeting.Droppinghis
safetybehaviourswasdiscussedasahomeworktaskand
writtendownonahomeworkassignment sheet sothe
clientcouldkeepacopyofwhathadbeenagreed Isee
Figure4.11:
Figure4､1
1．
John'sHomeworkAssignmentSheet
Whatistheassignment？(Statewhen・whereandhow
oftentheassignmentistobecarriedout｡)
DropmysafetybehavioursaithemeetingthisFriday
evenlnq･
ン
2．Whatisthepurposeoftheassignment？(Thisshould
fiowfromthesessionandbelinkedtotheclient'sgoal.)
‐｢btestmycatastrophicpredictionthatmyhandwil lshake
uncontroilablyif ldropmysafetybehaviours.
3． Troubleshootingobstaclestoassignmentcompletion
(￨'￨￨getsoanxiousaboutthingsgoingpear‑shapedifldrop
mysafetybehavioursthat l'llavoiddoingtheassignment'
Response: $l'mgoingtodothistaskcomeheliorhighwater!'
4． Contingencyplanifassignmentprovestoodifficultto
complete
Dowhatlcan・Notedownmythoughtsandfeelingsthat
got intheway.
68
777ejapﾉSr：
Jo/7n:
7 he旧p/sr：
Jo/7n:
777eﾉapjsf:
777eﾉap/si:
Jo/7n:
melapjsf:
[7 h/S/sihermub/es/7oor/ngp/7aseof/7omewoﾉkMscUss/on]
Jo/7":
Well, theonlyoneicanforeseeisgettingsoanxious
7herap/Sr:
that itwillallgopear‑shapedif idropmysafetybehav‑
ioursthat l'llavoiddoingthehomework.
Writethatdownthen.Canyouseeawaytoovercome
thatobstacIe？
Jo/7n:
Ws,bytel lingmyself@l'mgoingtodothistaskcomehell
me垣pisf:
orhighwaterl' l real lywanttoovercomethisproblem.
Good.Pleasewritethatdown.Nowthelast itemonthe
homeworksheet ishavingacontingencyplan ifthe
assignmentprovestoodifficulttocomplete,aplanBin
otherwords.
John:
Well,￨'lldowhatlcanandnotedownthethoughtsand
feelingsthatgot intheway.
69
エ◎ヨ⑩ミ︒﹃詩
Jo/7n:
What istheasslgnmentyouaregoingtocarryout？
Basedonourdiscussionsinthesession,droppingmy
safetybehavioursatthemeetingthisFridayevening
whichmeansIwon'tbeholdingmyselftightlyincheck,
grippingmypen,snatchingtheminutesfromthesec‑
retaryandrushingmysignaturetogettheordealover
withasquicklyaspossible.
Howwil lyouact insteadthen？
Well,what l'vebeenpractisingintoday'ssession. l'I Isit
back in thechaircalmlyandwaitpatientlyfor the
minutestobepassedtomebythesecretary. l'll take
thempolitelyfromhim,pickupmypen,spendseveral
seconds IookingattheminutesandthensIowlywrite
mysignature.All thiswiliprolongmyordeal .
Andwhat'sthepurposeoftheassignmentsor,asyou
said,prolonglngyourordeal？
‑Ibseeifmyfearwi llcometrue.
Canyouremindyourseifonthehomeworksheetwhat
yourfear is.
[w""nd$ Ibtestmycatastrophicpredictionthatmyhand
willshakeuncontrollablyif ldropmysafetybehavioursL
Canyouseeanyobstacles tocarryingout this
asslgnment？
7~helap/Sf
PIeasewritethatdown.Whateverhappenswiththe
homework, it isthelearningthatisextractedfromyour
attemptsthatwill bethefocusofournexthomework
review, not thesuccessor failureof theassignment
John
itself,okay？
Okay. 1'll rememberthat
ReviewingHomework
Assignments
Reviewinghomeworkassignmentsisakeyandearlyagenda
itemineverysession.AccordingtoBeckerQl. ,notreview‑
inghomeworkineverysessioncreatesthreeproblems:
■
この廷２．之応昌当且応﹄①全届の筐廷匡句︒︒
First, thepatientsusuallybegintothinkthatthehomework
isnotimportantand, therefore, thattreatmentissomething
donetothemratherthansomethingtheyactivelyworkon
evenintheabsenceofthetherapist.Second,thetherapists
missopportunitiestocorrectmistakessuchasthepatients'
inadequatelyresponding rationally to their automatic
thoughts.Third, thetherapists losethechancetodraw
helpfullessonsfromthehomeworkandtoreinforcethese
lessons. (1993: 109)
Ifacrisisemerges Iperhapsiftheclientcomestothesessionfeelingsuicidal), thishastobedealtwithimmediately
andhomeworkreviewissuspended,ifnotpostponed,until
thenextsession.Withregardtoreviewinghomework,preciseinformationisrequiredsuchasestablishingwhether
theassignmentwascompletedandhowthiswasachieved,
elicitingreasonsfornon-completionandpinpointingblocks
tochange.Theinformationgleanedfromthereviewcan
helPtodevelopaclearerpictureofclientS'problemsand
theadditionalstepsneededtotacklethem;confirmasteady
improvement intheirproblem-solvingabilities; orspur
themontocaPitalizeontheirsuccessbyundertakingmore
ambitiousassignments.
70
Reviewinghomeworkingeneralterms I77zempist:How
didyougetonwiththehomework?;CIie"r:Okay;TVze7α"ISt:
Good.Let'smoveonthenldoesnotbringanybenefitto
eithertherapistorclientasnolearninghasemergedfrom
theexchange. Insteadofskimmingoverdiscussionofthe
homeworkassignment,reviewingitmdetailnotonlyempha‑
sizesitsimportancetoyourclientsbutalsocommunicates
tothemyOurgenuineintereStintheirPrOgress.Tbreturnto
ourclient,John,hishomeworkassignmentwasreviewed
atthestartofthenextsession.
7 be'ap/sr:
me燈pjsr：
Jo/7n:
seewhathappens.
777erapjsr:
Now,canyoutellmewhatyouactuallydidwhenyou
behaveddi什erentlV？
Jo/7":
ltriedoutthosenewbehaviourslpractisedintheses‑
sion lastweek like leavingthepenonthetable,not
havingitreadyinmyhand, takingtheminutesfromthe
secretaryinotsnatchingthemandwritingmysignature
sIowly, not racingtodo it. I sIowedmyselfdownand
nothingterriblehappened.AIso, l addedsomething
extratotheassignmentwhichl 'mpleasedaboutwhile
IwaswritingmysignaturesIowly l lookedupfora
7 he旧p/si：
momenttoseewhatwasgoingon.
Whatdidyousee？
71
エ◎ヨのミ︒﹃詩
Jo/7n:
[rea耐"g/7omewoﾉkmrm]Wuragreedassignmentwas
todropyoursafetybehavioursat themeetingon
Fridayeveninginordertotestyourpredictionthatyour
handwill shakeuncontrollably ifyoudodropthem.
Howdidyougeton？
Well, l didthehomeworkand lwasquitenervous
aboutwhatmighthappen.Whatactuailyhappened
wasthatmyhanddidn'tshakeuncontrol1ably, justa
slighttremor, thatwasal l .However, 1'mnotcompletely
convincedyetthat itwon'tshakeuncontrollably.
Howcouldyoubecomemoreconvincedthe､？
Bynotreturningtomysafetybehavioursandjusttry‑
ingtobenatural andmorerelaxedatmeetingsand
Jo/7n:
Someofthecommitteememberswerelookingatme,
othersweretalkingtoeachother,someweredoodling,
othersseemedbored.
7he旧p陣：
Jo/7n:
Whatdidyoumakeofthat？
Bypayingattentiontowhatwasactuallygoingonout
there[pom伽gawaj//rom/7jSheacIratherthanrelying
onwhat l thinkwasgoingoninhere[iapp"79/7/s/bre‑
/7eadi gotarealisticpictureof howpeoplewere
behavingatthemeeting.
[Parrofh/sｵﾉearmenrpbn/se/ﾉC"mgaccL"臼re/nmrma"onnomfhe
exiema/env/ronmenr個的erｵﾉ7anrely/ngonh/s/nferna/andd/s‑
rorrediepresenfar/onsofiharenv"onment.]
一両巨的冒三応昌語ＱＥの塁ト①員逹堂動︒︒
777erap/Si:
Andwhatdidyouthinkwasgoingoninhere[rapp/ng
わぬheadwhenyoukeptyourheaddownandraced
Jo/7n:
Thattheywereailintentlystaringatme,knowinglwas
nervousandnudgingandwinkingateachotherabout
myhandvIsiblyshaking.
Sowhat lessonshaveyoulearntfromtheassignment
andtheextrabityouaddedontoit？
Well, nottobeguidedbymyanxiousthinkingabout
yoursIgnature？
777erap/Sr:
Jo/7n:
thesituationbuttobemoreoblectivebypayingatten‑
tiontowhat isactuallyhappening.Sol learntthatmy
handdidn'tshakeuncontrollablyandtheywerenot
scrutinizingmeinahighlycriticaIway,Theyprobably
couldn'tcarelessordidn'tnoticethat lwasnervous.
￨ 'msurethat'sthecase,
777elap/si:
Would l beright inthinkingthatyouarestillworried
aboutanypotentiallycritical reactionfromsomecom‑
mitteemembersifVourhanddidshakevisibly？
John:
777elap/si:
Yes,you'rerightaboutthat.
Might thatsuggestafuturehomeworkassignment
whichisinthetreatmentplan？
John:
Shakemyhanddel iberatelyandvisiblytoseewhatwil l
happen. l'￨￨ goalongwiththat.Makethat thenext
assignmentthen,
72
[Wher/7ersomecomm/rfeemembeﾉswou/dmakedSpaﾉagﾉ"g
肥maﾉks/fJomぢhanddds/7akeWS/bIMorevenuncon"ぬblWs
nor"7ecrLﾉc/a//Ssue:/7jsJeac"oniosIJc/7commenis/S.Ar"7ep/e‑
senfr/me, /7eWews/7/mse//as'weak'/brbe/ngnervoIJs‑的e/7aﾉs/7‑
eSfC""Car"7emeeimg/S/7/mse/〃""Tenexrc/7apieﾉ;neWWaj/sof
/ookmgar/7/mse/fw"/7/7/svuhTe/ab"/"esw7"beeXam/hed.］
所eﾉapjsi:
Okay.Wecandiscussthedetailsofthatassignmentat
theendofthesession.Nowlet'smoveontotheother
agendaitems.
Therapist'sReactionstoHomework
Non‑Compliance
Whensomeclientsdonotcarryouttheirhomeworkassign‑
ments, thetherapistmayneedtomonitorherreactiontothis
becauseclientnon‑compliancemeanJ1'manincompetent
therapist'.Intheseexamples,thetherapistneedstoexamine
hermaladaptivethoughts!withorwithoutthehelpofa
supervisororcolleague, andmakeadaptiveresponses to
them,respectively: 'Therapyisnotbasedonanequivalence
ofeffort.Myeffortorroleishelpingmyclienttoincreasehis
prOblem‑solvmgabilities' ;and'Mycompetenceasatherapist
isnotdependentonmyclientcarryingoutherhomework
thoughlcertainlywanttoimprovemyclinicalskillsinfind‑
ingwaystotacklemoreeffectivelyclientnon‑compliance'.
Suchresponseshelpthetherapisttoreturnherclinicalfocus
towhereitbelongs‑ontheclient'sproblems. IWewould
stresstheimportanceofregularclinicalsupervisionforther‑
apistsandapplyingtheprinciplesandtechniquesofCTto
themselves,notjusttotheirclients. 1
Asclientsmakeprogressinidentifyingandmodifyingtheir
NAIbandcarryingout homeworkassignments inthe
73
エ◎ヨの弓︒﹃詩
non‑complianceasproblematicthoughtsandfeelingscanbe
triggeredwithinher.Fbrexample,becomingangrybecause
theclientis 'notworkingashardaslam'orfeelinganxious
situationswheretheirproblemsoccur, thefocusoftherapy
shiftstodeepercognitivelevels!namely,underlyingassumptions, rulesandcorebeliefswhicharethesubjectofthe
nextchapter.
Notes
1
Greenberger andPadeskyhavewrittenastructuredseif-help
cognitivetherapymanual forclientscalledM/ndOverMood(1995).
Theauthorsguideclientsthroughthestagesofidentifyingandmod-
ifyinghotthoughts,underlyingassumptionsandcorebeliefsinorder
tionships'(1995:2).Thereareexercisesforclientstocomplete in
eachchapter.Themanualcanbeusedwhetherornotthepersonis
intherapv.
ず
２
一両︽耐冒三個Ｅ豈旦囚曾匡のミ彊己︒︒
to{makefundamentalchangesinyourmoods,behaviors,andrela-
Progressivemusclerelaxation (PMR) helpsclientstorecognize
thedifferencebetweentensionandrelaxation ineachofthemajor
musclegroups.ByteachingclientstoalternatebetweentensIon
andrelaxation, theylearntodistinguishbetweenthesetwostates
andbecomemoreawareoftense@troublespots' inthebodywhich
requireparticulara廿ention.PMRtakesbetweenl5‑20minutesto
complete.
74
UncoveringaりdExamining
UnderlyingAs釦師fons,Rulesand
Cc絶Be1iefs
Unhelpfulunderlyingassumptions,rigidrulesandnegative
corebeliefswerediscussedinChapterlbuttorefreshyour
memory: unhelpfulunderlyingassumptionsI'1flalways
pleaseothers, thentheywon'trejectme' ) andrigidrules
￨'1mustalwaysstrivetodomybestatalltimes')providea
codeofconductforoperatingintheworld.However! ifthe
termsoftheassumptionsarenotmetlthepersonisrejected)
orrulesarenotadheredto lthepersondoes less than
hisbest),thennegativecorebeliefsabout theselfl'I'm
unlikeable'l,others (!Noonecanbetrusted' )ortheworld
('Everythingisagainstme')areactivatedandaccompanied
byintenseemotionaldistress.Assumptions, rulesandbeliefs
areuSuallyformedearlierinlifeandoftenremainunspo‑
ken−asilentpresenceinthepersoniSmind−andtherapy
maybethefirsttimetheyaremadeexplicit.
Exploringdeepercognitivelevelsusuallybeginswhen
clientshavegainedsome skill andconfidenceiniden‑
tifyingandanswering theirNAIb (negative automatic
thoughts) throughcarryingouthomeworkassignments.]
ThcklingthesedeeperlevelsfirstandbypassingtheNAIb
stagemayreSult inclientsfeelingoverwhelmed, threat‑
ened,overlydistressedorresistantbecauseofthetherapist
'goingtoodeep, toosoon‑astrategywhichmayleadsome
clientstoterminatetherapyprematurely.Havingsaidall
that,wehaveworkedwithclientswhowerereadylwilling
andabletoworkoncorebeliefsearlyonintherapy('Let's
gostraighttothesourceofmyproblemsaslknowwhatit
isandnotwastetimeonthesymptoms｣ ).2
ldentifyingUnderlying
AssumptionsandRules
Revealing:lf…then'or:Unless｡.｡
then'Statements
Clientsoftenexpress theirassumptions inthese terms
￨'Unlessldoeverythingwell､henpeoplewon'twantto
knowme'lbutmaynotrealizewhattheVhavearticulated
P
ユ
エ
一芯この胃之町ミ当旦廻の全ト①ミ廷匡句︒︒
untilyoubringittotheirattention{'Isthatanimportant
assumptionwhichguidesyourbehaviour?'l . Sometimes
assumptionscanbedifficultfortheclienttospotandthe
therapistneedstohelphimteasethemout. Inthisdia‑
logue, theclient'whocallshimselfa'massiveworkaholic' ,
ishelpedtoseetheundesirableimplicationsofhis'mission
statement'whenitistranslatedintotheformofanegative
assumptlon:
C"enr
Gettingahead in life isreally important tome. l've
reallygot topushmyself hard.That'smymission
statement，
刀7eﾉapﾉSi
Andifyoudon'tpushyourselfreallyhardtogetahead
inlife､ thenwhat？
｢7 he"7elap/s中ﾉDV/咋sfhe7f…'parrofiheassum"on"7oﾉderfo
encou/age"7ec"enrro伽加的e'｡,."7en'co"c/us/on｡1
C//enf:
Thenmyl ifewi llbewastedandl 'dhavefailed
DiscemingThemesinClients'
AutomaticThoughts
Thetherapistcanreviewcollaborativelytheclient'sdaily
thOughtrecordsIDTRsl inordertodiscernrecurringthemes
inherautomaticthoughts.Forexample,asampleofherauto‑
maticthoughtswere: 'Ineedtoensurethatpeopleseemein
76
therightway','1can'tstanddisorderinmylife'and'Things
havetorunsmoothly'.Throughdiscussion, theclientwas
abletoelicitthethemeofcontrolandputitintoassumptive
form: 'Unlesslhavecontroloverthingsinmylife, then
everythingisgoingtofallaPart'.
FamilySayings,Memories,
Mottoes(Fennell,1999)
Aclient'srulesandassumptionscanbetracedbacktocermottoes.Aclientrememberedherfather'ssternwarning:
jlfyoucan'tdosomethingwell, thendon'tdoitall'.The
clientsaidthatabsorbingthispieceof 'wisdom' fromher
fatherhelpedtomakeherfearfulofmakingmistakesand
apatternofunderperformingdevelopedinherlife.
AskTheClient
Aswehavesaidearlier inthischapter, assumptionsand
rulescanbeunarticulatedandthereforehavetobeinferred
fromclientclueslikecombingthroughtheirDTRformsto
findrecurringthemesintheirthoughts.However, itshould
notbeoverlookedthatthemostobviousandstraightforwardwaytoelicitanassumptionorruleistoasktheclient:
7 heﾉap/sr
We've lookedatanumberofsituationswhereyour
ownneedsareneglectedinfavourofotherpeople's. Is
therearuleorassumptionyou'refollowing inthese
situations？
C"eni
Yes, thereisarule: Ishouldalwaysputotherpeople's
interestsandneedsbeforemyown.
Fennellsuggeststhatrules 1usuallylinkupwithahidden"or
else"' (1999: 166) . Intheaboveexample,theclient'shidden
'orelse'was: 'orelselwillbeseenasselfishandunkind
andthennoonewillwanttoknowme'.
77
こ︒Ｑのユミコ廻遅の的ミヨ耳ざごいコミのの四．Ｑｏｏ愚︑哩討計
tainearlymemoriesorderivedfromfamilysayingsand
Pinpointing;Shouids'andnMusts'
Personalrulesareoftene"ressedin'should' and'must'
statementssuchas'Ishouldneverappearineptinsocialsituations' and'Imustappearstrongandcapabletomycolleagues'.Astheexamplesshow, theserulesaremaladaptive
becausetheyareinHexibleandthereforehave 'nothingto
say' aboutcopingconstructivelywhentheserulesarenot
adheredtolforexample,aclientspillshisdrinkoversomeoneelseatapartyandleavesthepartyimmediatelyunable
todealwithhiUexcruciatingembarrassment').Clientscan
learntospot'shoulds'and'musts'intheirthinkingwiththe
therapist'sprompting:
一句垣２．之殉ミ語具価可︽仁①ミ鐘匡動︒︒
C"enr
Whenmyson isnaughty, l feel it'smyfault thathe
behavesthatwaybecauselshouldbeabletocontrol
hisbehaviouratall times.
7 helap/Sr
C"enf:
【emp/7aijCa/M@Shouldbeableto…，
AIright.Therelgoagainwithoneofthosebloodyrules
ofmine, Idousethat
所elapjsi
C//enf:
should，aIot,don,t l？
"ucertainiydo,andwhat'stheeffectonyouwhen
youdon，tdowhatyoushoulddo？
￨ feelbadbecause, inthiscase, ￨ 'mnotabletocontrol
mvson'sbehaviour.
＝
TheDownwardArrowTbchnique
(BumS,1980)
This involvesencouragingclientstopursuethepersonal
implicationsofaparticularlyhot lemotionallycharged)
thought.Thetherapistasksvariationsofthequestion'What
doesthatmeantoyou?' inordertopeelawaylayersof
thoughttouncoveranunderlyingassumPtionorcorebelief.
UnlikerespondingtoNAIb,eaChthoughtuncoveredbythe
downwardarrowtechniqueisacceptedastemporarilytrue
untilanassumptionorruleisdiscovered. Inthisexample,
theclient isveryanxiousaboutgoingoutwithanew
78
boyfriendasshestronglybelieves,｣Ijustknowit'snotgoing
toworkout' (hotthought) :
Theﾉapjsr：
Andifitdoesn,tworkout,whatwouldthatmeantoyou？
C"enf:
ltmeansthathedoesn'twantme.
所eﾉap/sr：
Andifthat istrue, thenwhat？
C//enr:
Herewegoagain.
7 heﾉap/sr：
Whatdoesthatmeantoyou,
C"enf:
That l'monmyownagainbecausenomanwantsme.
777e砲p/sr：
Andwhatdoesthatmeantoyouifnomanwantsyou？
Cﾉﾉenf;
[fea""/]That l'malwaysgoing tobealoneand
↓
herewegoagain'？
↓
miserabie.
[777ec"enr台reaﾉs/nd/Careiharan/mPorranrbe"ef/7asbeen/ocared
burr/7e"7e'ap/Sichecksbymed/hgbackro"7ec//enfherimp/jed
assump"on.]
刀7eﾉap/sr
Woulditberighttosaythatyoubelieveifnomanwants
you， thenVouwill alwaVsbealoneandmisel●able？
[c//enmods].
Beckpointsoutthat 'askingwhatathoughtmeanstothe
patientoftenelicitsanintermediatebelief[assumptionor
rulel; askingwhat itmeansqbo"thepatientusually
uncoversthecorebelief' ￨1995: 145; italicsinoriginal).We
willbe lookingatuncoveringcorebeliefs throughthe
downwardarrowtechniquelaterinthischapter.
79
コミ①切望昌○ミ①画里慰苛
I
筐．Ｑ２ミヨｂ遅いのこョ頁冒︒
↓
ldentifyingJohn'sUnderlying
Assumptions
John,ourclientwithsocialphobia,haddevelopedconsiderableskillinidentifyingandrespondingtohisNAIbwhich
hadledtoreductionsinhisanxietylevelsbefore, during
andafterbemg'inthespotlight'atmeetings.Johnhadwhat
hecalledsome 'troublingbeliefs!hewantedtolookat, so
thefocusoftherapynowswitchedtounderlyingbeliefs.
777elap/Sf: ThoseNATsofyourswe'vebeenexaminingstemfrom
deeperbeliefs[c"enfnodsIUoIDusM.Cognitivetherapy
seestherelationshipbetweenthoughtsandbeliefsin
一両垣２コ之︑ミ巽旦図の曇ト①量這匡画︒︒
thisway[dﾉawｿngon"7ew/7/ieboa'd]:
Negativeautomaticthoughts
↑
Assumptions/Rules
･
↑
CoreBeliefs
Thenextstepdownwards,sotospeak, istolookatthe
assumptionsorruleswhichguideyourbehaviourbutare
nothelpful indealingwithyourproblem;theyactuallymain‑
tainitbydictatingtoyouwhatbehaviourandstandardsare
acceptable,whatkindofpersonyoushouldbe,whatisper‑
missibleinyour ilieandwhat isn't.UnibitunateIMwhen
theseoftenexactingstandardsarenotmet, theconse‑
quencescanbe, intheperson'smind,catastrophic.
Jo/7n:
Tbllmeabout it. l 'mdrivenbythisideaofnotappear‑
ingnervousorweaktoothersparticularlytothosewho
mightuseitagainstme.
[777epaﾉ加U/a〃…'parioftheassumpWOnwasiheonlysﾉﾛ"/#banr
aMr/onroJo加怠/n/rla/caseconceprua/iza"on;seeif7esec"bnon
coIebe"e/Sandunde"ymgassump"ons/hC/7aprer2.1
80
所eﾉap"
But ifyoudoappearweakandnervous toothers
pamcularlytothosewhomightuseitagainstyou, then
what？
[7 heiheﾉapﾉsrseeksromake"7eassL"刀"onexpﾉに〃byp'oWding
的eガ心fparfo砿7fj/oU血…'and"71/ifesIhec//enrIocomp/erer/7e
$"7en…'parr.]
John
Then l'llbeharshlycriticized, rejectedorhumiliated. l
knowit'sallutterrubbish. ifmyhandshakesatthemeet‑
ingmycredibilityaschairmanwillnotbedestroyedeven
Jo/7，
ExaminingUnderlying
AssumptionsandRules
BehaviouralExperiments
Padesky (1994) states thatunderlyingassumptions are
oftenbesttestedthroughemployingbehaviouralmethods｢ so
aclientwhobelieves｢ 'Ifltellmyfriendsthatlamaformer
alcoholic, thennoneofthemwillwanttoknowme' ｢mentions
hispastdrinkingtoafewcIosefriendstogaugeinitialreac‑
tionsbeforetellingawidercircleoffriends.Behavioural
e"erimentsareapowerfulwaytomodifymaladaptive
81
ごコ旦廻ミヨ垣垂切の宮ョ頁冒︒ｐコミ①の鼬︒Ｑｏｏ扇︑里苛苛
7~helap/Sr
ifsomemembersenjoywitnessingmydiscomfort.Even
morestupidly, inmywildestmomentslbelievenoone
willwantmeastheirGPanymore.Howinheaven's
namemypatientswouldfindoutaboutmyhandshak‑
ingorevencareaboutitdefieslogic,butthereyouhave
it: that'swhathappenstomewhenl'minthegripofmy
anxietyaboutbeinginthedamnspotlight.
Let，sdosomethingabout it､okay？[c//enfnodsI,Let，s
testoutthisassumption, asyoudidwithyourauto‑
maticthoughts, andsee ifwecandevelopamore
reasonableresponsetolt･
1'mready.
assumptionsbecausetheyarebasedoncollectingobjective
evidenceinordertotestthevalidityoftheassumption. In
theaboveexample, theclientwas toldbysomeofhis
friendsthattheyalreadykneworhadguessedhehadbeen
analcoholic・Hisnewassumptiongeneratedbytheevidence
fromtheseexperimentswas: 'Ifl tellmyfriendsthat l
amaformeralcoholic, thenmostwillstillwanttoknow
meandafewwillnoti.Fennellsuggeststhat 'alternatives
todysfunctional [unhelpfullassumptionscanbewrittenon
flash‑cardsforpatientstoreadrepeatedlyuntilactingin
accordancewiththembecomessecondnature' ￨1989:2071.
凸
菫のこの胃三町ミ碧旦侭句塁トの這這巨句︒○
QuestioningtheValidityofthe
PersonalContract(Blackburnand
Davidson,1995)
Thisreferstoclientsbeingaskedtoreviewthetermsofthe
personalcontractsIassumptions,rules)theyhaveconstructed
forthemselves.Forexample,aclientconsideredwhetherher
owncontract,'Iflhelpothers,thentheymusthelpmeI,real‑
isticallyrenectedherrelationshipswithothers: 'No.When
someofthemdon'thelpmewhenlaskfor.it,Ifeelbitterly
disappointedandangryWhycanittheybehavelikeldo？I'm
alwaysthereforthem｢. Shedecidedtorewritethetermsof
thecontractmorereasonablyandrealisticallyIshestopped
demandingthatthetermsofthecontractmMsrbefulfilledl:
'Iflhelpothers,whichlliketodo, thenldon'te"ectthem
toautomaticallyhelpmewhenlaskforit.Sometimeshelp
isgivenwhenlneeditandsometimesitisn't'.
ListingtheAdvantagesand
Disadvantages
Clientsareencouragedtolistandexaminetheadvantages
anddisadvantagesofholdingaparticularruleorassumption・ Inthefollowingexample, thecnent'sassumptioniS
82
writtenonthetherapistIswhiteboardinherofficeandthe
whiteboardisdividedintotwocolumns:
Assumption:$lfldon'tgetclosetoothers,thenlwon't
gethurt'
Advantaqes
1.Keepsmesafe
DisadvantaqeS
l.lmisscIosenessand
2. Avoidrejection
2But laIsoavoidhavinga
relationship
3． DOI？Thenwhydolget
depressedaboutbeing
lntImacv
lhaveemotionaIcontrol
~
onmvown？
4.
Livingtherestofmylife
alone
5.ldon'tleamhowtocope
withmyhurtfeelings
whenl'mrelected
Disadvantagesusuallyoutweighadvantageswiththistechniquethoughthetherapistmayneedtohelptheclient
elicitdisadvantages ifhecanonlythinkofadvantages.
Additionally, clientscanre-evaluatesomeofthesupposed
advantages: 'KeepsmesafetobemiSerableandlonely.
You'resupposedtofeelhappywhenyou'resafe.Whata
jokemylifehasbecome'.WithdiSadvantagesoutweighing
advantagesandsomeoftheadvantagesre-evaluatedas
self-defeating,clientsaremorelikelytoinitiatechangeand
therebydevelopamorehelpfulassumption: !Gettingclose
toothersmayinvolvegettinghurtbutthisisapriceworth
payingforthepleasureofarelationship!howeverlongit
lasts. Ifldogethurt｢ thenlcanlearntocopewithit
differentlythanldidinthepast'.Theclientcanalsolookat
theadvantagesanddisadvantagesofhisnewassumptionto
remindhimselfoftheprobablepleasureandpossiblepain
hemayexperienceinarelationship, forexamPle,mutual
83
こ︒Ｑ２ご言い垂いいこョ真﹃ｇ耐電コミ①いい︒Ｑｏｇの︑哩耐計
3．
loveladvantagelvsbeingrejectedldisadvantagel;inother
words,itwillnotbeallplainsailing.
HistoricalDevelopmentof
AssumptionsandRules
一恵廷幽．ｚ︑星蚤Ｑ屈む兵ト①畠室匡画○○
Clientscanprofitfromlearningaboutthedevelopmentof
theirunhelpfulrulesandassumptionsinordertounderstandhowtheystillhaveanadverseimpactontheirlives
today.Thisdevelopmentusuallystartsinchildhoodlbut
notinevitablyso)aschildrenformassumptionsorrulesin
thelightoftheirexperiencesandrelationshipswithothers.
Forexample! achildwhohasangryandunpredictable
parentsbelieves 'Iflalwaysdoasl'mtold, thenlwon'tbe
shoutedatorhit'.Thisassumptionwasadaptiveatthetime
toavoidbeingpunished,butinadulthoodthisassumption
hasbecomemaladaptivebecauseitdoesnotreflectchanges
inherlifeandrelationships;shestillremainssubmissivein
herdealingswithothers- 'Idon'tlikebeinglikethis,but
I'mstillwaryofpeoplebeingangrywithme'.
BYcomparingtheoperationoftheassumptioninchildhoodwithitsoperationinadulthood, theclientcandetermineifthesameunpleasantconsequencesstillholdtoday
'Ifldon'talwaysdoaslrmtold'.Suchaninquiryandthe
findingsfromitledtheclienttodevelopanewandmore
adaptableassumptionthroughbeingassertive,whennecessaryl inherrelationships:'Ifsomepeopledogetangrywith
mewhenlstandupformyself/ thenlcanspeakbackasa
confidentadultratherthanasafrightenedchildr.
DisobeyingtheRules(Becketa1.,1979)
Aswehaveseen,rulesoflivingareoftenexpressedinrigid
mustsandshoulds,forexample,'Ishouldneverrevealmy
deepfeelingstoothers/withthetacit 'orelse' followmgonjorelselwillberidiculedasalonelyoldspinster'.Oneway
tochallengethe 'should', asintheaboveexample, isfor
84
theclienttodisobeyitinordertodiscoverifherprediction
isaccurateandtherebyprovidepotentialopportunitiesto
modifyherrule.Theclienttoldafriendofherloneliness
andunhappinessinbeingwithoutapartnerandherfriend
suggestedshecamealongona 'nightoutwiththegirls'.
Theclientwasabletomodifyherbelief, 'Icanrevealmy
deepfeelingstootherswithoutbeingridiculed',because
herpredictionhadbeendisconfirmedand, tohersurprise!
somesocialopportunitieshadtherebyopenedupforher.
InthepreviousdialoguewithJohn, akeyproblemperpetuatingassumptionwasidentified: 'Iflappearweak
andnervoustoothersparticularlytothosewhomightuse
itagainstme, thenl'llbeharshlycriticized, rejectedor
humiliated'.Thefollowingdiscussionlooksattestingthe
validityofthisassumption:
Jo/7n;
Therapyhasbeenmoving inexorablytothispoint: to
deliberatelyandveryvisiblyshakemyhandwhilel'm
signingtheminutestoseethereactionsofthecommittee,particularlythosewhol thinkhavegot it informe｡
777eJapjSr:
John:
Whatwillhappenifyoudon'ttestoutthatassumption
ofyours？
lknowitwillcontinuetoplayonmymindandkeepmy
Tbeﾉap/sｵ：
anxietygoing.
AndifyoudocarrVitout？
Jo/7/7:
777efap/Sr:
1 'll befacingmyfearand l knowI'll beableto live
through it.As I saidbefore, l knowit'saloadofold
nOnsense[raPP"1g/7/S/7ea(I,
Sowillyouputthis:loadofoldnonsense'tothetestas
vournexthomeworktask？
Jo/7n:
Definiteiy. ￨nacuriousway, ￨ 'mlookingforwardto it.
￨ reallywillbeinthespotlightnowasl'llbesaying, $Hey,
lookatme.Myhand'sshaking'.
85
ごコＱ２ミヨ垣垂切の宮ョ頁さ．少コミ⑩の助弓ＱｏＯ扇町里討計
ExaminingJohn'sUnderlying
Assumptions
TheoutcomeofJohn'sexperimentwasnon-catastrophic:
hesaidacoupleofthecommitteemembersaskedhimifhe
wasokaywhileonememberwhoJohnbelievedhad'itin
forme' smirked：
Gottheshakes,oldboy？Gladyourenot
asurgeonandl'mnotoneofyourpatients.' Johnsaidhe
brushedoffthelastremarkaJpointscoring'.Heconsid‑
eredtheexperimenttohavebeenananti‑climax: 'Iwas
fearingtheworstbutnothingmuchhappenedatall'.
Tbaddtohissurprise, ashewasnolongerbothered
whetherornothishandshookinfrontofthecommittee
members,hesaid, ｣Myhandfeelslikeforthefirsttimethat
itisundermycontrol! Ihestretchedhishandoutinfront
菫幽茄冒之応ミ謡Ｑ屈む塁トのミ廷ご動︒︒
ofhimtodemonstratehisnew‑foundcontroltothethera‑
pist).Justtoensurethathewasnolongerbotheredabout
displayingnervousnessinfrontofthecommittee,hesaid
hewOulddeliberatelyshakehishandatsomemeetings 'to
keepmyhandin, sotospeak'.
ldentifyingCoreBeliefs
Negative corebeliefs are fundamental andabsolute
appraisalsofoneselfI1I'maphoney'|,othersIEveryonewants
toexploitmeinsomeway') andtheworld('Theworldis
againstme'l.Someofthesametechniquesareusedforidentifyingcorebeliefsasforunderlyingassumptionsandrules
|forexample'discerningthemesinclients'NAIbandasking
theclient). Inthissection, thedownwardarrowisdemonstratedagainandnewtechniquesofsentence-completion
andconjunctivephrasingarepresented.
TheDownwardArrow
Asweexplainedearlierinthechapter/thistechniquebegins
withtheclientselectingapamcularlyhotthoughtasthe
startingpointfordeepercognitiveexplorationbypursuingthe
86
meaningtheclientattachestoeachrevealedthoughtuntil
the ｣bottomline' Icorebelief) isreached.Inthefollowing
example,theclientisworriedaboutherhusband'swishto
gooutaloneratherthanstayhomewithher:
777eﾉap/sf：
Ifthat isthecase,whatwouIdthatmeantoyou？
C//enr:
Thathe'sfoundanotherwoman.
7 he旧p/sf：
Andifhehas？
C"enf:
Thenhe'll leaveme.
me煩p/s#：
Ifhedoesleaveyou, thenwhai？
C"e"f:
1 'llbealone.Hedoesn'twantmeanylonger.
777eﾉapjsi:
Whatdoesthatmeanaboutyouifhedoesn'twantyou
anylonger？
↓
↓
[Askmgc//eniS'Whardoesrharmeanabourj/ou?' /nsreadof 'io
you?'Lﾉsua/Mylevea/sacorebe"ef]
↓
C"enf:
[fea"uMI'mrepulsive[corebe//e1.
Sentence‑Completion
Thetherapistcanwriteonherwhiteboardoronapieceof
paperthefollowingunfinishedsentencesandaskherchents
to'fillintheblanks' inordertouncovertheircorebeliefs
aboutthemselves,othersand/ortheworld:
●
●
●
Iam…[undesirable]
Peopleare…[untrustworthy]
Theworldis…[dangerous]
87
と．Ｑミミヨロヱの２ミ︾頁ざ．ゆコミ⑩の鼬．ＱｏＯ扇国璽耐貯
↓
Anotherexampleofsentence-completionisfortheclient
torespondtothetherapist'sprompt linthiscase, theword
'because'l torevealacorebelief:
C//eﾉ7f:
l 'mscaredstiffof itailgoingwrongwhen l givethat
presentationtothepsychiatrists.
7beﾉap/Sf:
Andyou'rescaredstiffof itallgoingwronginfrontof
thosepsychiatristsbecause…？
C//enf:
Because itwill prove l'mincompetent [corebeliefl.
ldon'tknowmysubject.
ConjunctivePhrasing
(Walenetal｡,1992)
■
C//enf
ｓ
Ｓ
＃
Ｓ
ｉ
ｐ．．ｐ・・ｐ・・
ｒ
垣 ︑ 煩 ︑ 煩 ｍ
所ｅ酬ｅ乃ｅ即ｅ所ｅＣに
一両垣２コ之応ミ語旦侭竜⑩全ト①崖﹄旨︑ｏ○
Thisreferstotheuseofsuchphrasesas 'andtherefore… ，
'andifthat'strue…!or'andthen…′ tonudgetheclient's
trainofthoughtalongtoitsdestination・ The therapist
removesthefullstopattheendoftheclient'ssentenceand
replacesitwithaconjunction:
| worryabout not beinggood inbedwithmy
girlfriend.
Andif it'struethatyou'renotgoodinbedwithher…？
She'll lauqhatme.
ゞ
Andthen． . ．？
She'lldumpme.
Andifshedoesdumpyou…？
ltwillprove l 'mnotarealman[corebelief]・Useless
inbed.
ldentifyingJohn'sCoreBelief
Johnwasveryclearwhathiscorebeliefwasashehadmentioneditseveraltimesineverysession''1'mweak' Iseethe
caseconceptualizationinChapter21:
Jo/7n:
Thatbeliefhasbeenlurkinginmymindforalongtime.
Iwanttogetridof it.
88
刀1eﾉapﾉSr
Okay.Shallweworkonreplacingthatcorebeliefof
yourswithsomethingmorepositiveandhelpful？
Jo/7n:
lt'sIongoverdue.
ThreeProcessesforMaintaining
CoreBeliefs
1
2
３
Schennannamtenance.Thisreferstowaysofthinkingand
behavingthatperpetuatecorebeliefs,perhapsapersonwho
seeshimselfas 'notgoodenough'doesnotpushhimselfin
anyareaofhislifeashealwayssettlesforsecond-best.
Schemaavoidance・Thisreferstothecognitive,behavioural
andemotionalstrategiesthatapersonusestoavoidacti‑
vatinghercorebeliefandthepainfulfeelmgsassociated
withit! forexample, awomandrinksheavilyto 'drown
out' thememoriesoftheendofhermarriageandseeing
herselfasunwantedi however, tryingtoblockouther
unhappinesscontinuallyremindsherthatsheisunwanted.
Schelnacolnpensation.Thisreferstowaysofthinking
orbehavingthatapersonengagesintocontradictor!fight
back'againstthecorebelief・Apersonwhoseeshimselfas
unlikeabledoeshisbesttocultivateawidecircleoffriends
toproveheislikeable;whenfriendsdriftoutofhiscircle,
donotreturnhisphonecallsorrecoilfrOmhisoverfamil‑
iaritv, itreinforcesinhismindthathereallVisunlikeable
エゥ
andthatallattemptstoproveotherwisearefutile.
Johnsaidthatschemacompensationhadbeenhismaladaptivecopingstyle: hekepttryingtoprOvetohimself
'I!mnotweak'byattemptingtokeephimselfundertight
controlwheninthespotlightatmeetings.However, the
intenseanxietyheexperiencedbeforeandduringtheearly
89
こ．ｑ里・ミヨロエいいこヨ℃﹃さ﹃耐画コミのり則．Ｑ○○﹃の︑里耐苛
WediscussedinChapterlwhatcorebeliefs Ischemas)are
andhowtheydevelopastheresultofearlylifeexperi‑
encesinowwelookatthreemaladaptiveprocessesthat
reinforcenegativecorebeliefs (Ybung, 1994).
partofthemeetingdemonstratedthathewasnotincontrol
ofhimselfandthereforetherecouldbeonlyoneinescapable
conclusion‑'I'mweak'．
ldentifyingAIternativeCoreBeliefs
Assoonasclients' corebeliefshavebeenuncoveredand
schemaeducationhasbegun,itisimportanttoidentifyand
startdevelopmgalternativeandmoreadaptivecorebeliefsin
orderforthem,notthenegativecorebeliefs,tobeatthecen‑
treofclinicalattention.Thisisilnportantbecausemoving
awayfromanoldandunwantedbeliefbuthavingnothing
toreplaceitwithmeansthatclientsdonothaveavisionof
一遍この冒之殉ミ蚤Ｑ国司塁ト①堂堂巨句︒︒
newandappealingpossibilitiesfortheself.Additionallyi
'changeincorebeliefsorschemasoccursmorerapidlyif
therapistandclientfocusonbuildingnewschemasrather
thanmerelytestinglandmodifyingloldones' (Mooneyand
Padesky,2000: 150‑511 .John'snewandadaptivecorebelief
wasTmacompetentpersonwithvulnerabilities'.Thisbelief
wasadaptivebecauseitrepresentedabalancedviewof
himselfandhislife,andhisvulnerabilitieswerenowtobe
managedwithoutself‑condemnationl'Ifmyhandshakes,
sobeit.Mynervousnessispartofme'l.
DevelopingNewCoreBeliefs
(SchemaChange)
"desky{19941advancesthreekeyschemachangemethods:
useofacontinuum,positivedatalogsandhistoricaltests
ofaschema.
UseofaContinuum
Clients'negativecorebeliefsareoftenconstructedinall-ornothingterms, suchas:'Eitheryou'reasuccessorafailure
90
inlife'.TheuseofacontinuumIsaylascalefromOpercent
tolOOpercentlintroducesshadesofgreyintosuchthinking, therebyhelpingclientstoarriveatmorebalancedand
realisticappraisalsofthemselves, othersandtheworld.
PadeskyandGreenbergersuggestthat
ascaleorcontinuumismosttherapeuticwhenitisconstructedanditsdataevaluatedforthenewschemarather
thatweakenstheoldschema.(1995: 144)
Forexample, ifschemachangeisevaluatedalongacontinuumfocusingontheoldbelief l'1'mafailure'1 , theclient
might seehimselfnowas 'only80percentafailure',
whereasifchangeisevaluatedalongacontmuumofhis
alternativebelief ('I'msuccessfulattimes. Ibelievethat
20percentatthepresenttime'l,optimismisencouragedand
likelytostrengthenashispercentageratingsrise,basedon
theevidencecollectedovertheweeksandmonthstosupユ
porthisnewviewofhimself. Itisimportantthattheend‑
pointsonthecontinuumarestatedinextremetermssothe
clientcanseethatchangeisoccurring,whereasiftheend‑
pointsarestatedinmoderateterms,noticingchangecan
beharderfortheclienttodetect.Theuseofacontinuum
helpstheclienttoshifthisextremethinkingintothemid‑
point (non‑extreme) range.Johnhada30percentbeliev‑
abilityratinginhisnewcorebeliefwhenthecontinuum
wasconstructed:
Newcorebelief: I'macompetentpersonwithvulnerabilities
0％
30％
50％
100％
−×
AIwaysvulnerable,
Competent
AIwayscompetent,
nevercompetent
andvulnerable
nevervulnerable
91
写量叫ミョ廻延切りミゴ頁ざ．即刀ミのの四コｑ○．耐︑里荷静
thantheold・Asmallshiftthatstrengthensthenewschema
isusuallymorehopefulfortheclientthanasmallshift
Thecontmuumcanbeusedregularlyasareferencepointto
momtortheclient'sprogresstowardsthe'middleground'of
thecontinuum,basedoninformationcollectedfromvarious
sourcessuchaspositivedatalogs.
PositiveDataLogs
一芯こ２．三吋Ｅ語Ｑ層里置のミ室厘画︒︒
Keepingaloghelpsclients tocollect informationfrom
homeworktaskstosupporttheirnewadaptivebeliefs.This
methodreducestheirtendencytodiscountpositiveinformationandfocusonlyonevidencethatappearstoendorse
theiroldbelief.Positivedatalogsseektocorrectbiased
informationprocessingsuchasmind-reading, labellingand
jumpingtoconclusionsIseeChapterll.Tbprovidearationale
forundertakingpositivedatacollection'"desky (1994)
suggeststhemetaphorofselfprejudice:maladaptivecore
beliefsarefirmlyheld, likeprejudices, inthefaceofcontradictoryinformationthatcoulddiscreditthem.Johnfound
theideaofholdingaself-prejudiceanunsettlingrevelation
becausehesawhimselfasadheringtoa'liberal!progressiveoutlook'.Wantingtofreehimselfofsuchaprejudice
hastenedthechangeprocess:
ﾉo/7n:
￨'vesaidtoyouonanumberofoccasionsthatsome
ofthecommitteememberswerewhat l cal loldreac‑
tionariesfortheirviewsonwomen, ethnicminorities
andothers. l'mjustasbadastheyarewhenitcomes
tomejudgingmyselfasweakforbeingnervousThey
don'twanttochangetheirfixedviewsandldidn'twant
刀7eﾉap/sf:
tochangemyfixedviewofmyself.
Canyouseehowyour self‑prejudicehas been
maintained？
Jo/7n:
YesIcan.Forexample,mywifehastoldmeoverthe
yearstostopbeingsohardonmyselfandgetridofthis
nonsenseaboutbeingweak.Shesaidif l'dbeentruly
weak, thenl'dhavecrumbledeverytimel facedacrisis
inmylife.Ofcourse, l discountedherviewsbecause
92
Theﾉap/St
theydidn'tagreewithmine. lfyouwereareally､rong
person,youdidn'tshowanyweaknessever.
Wouldyousaythatyournewcorebelief, &1'macompe‑
tent personwithvulnerabilities' , represents self‑
enlightenment ratherthanseif‑prejudice, compassion
insteadofharshness？
Mostdefinitely.
777elapjsf
Whatevidencedoyouhavetosupportthatreply？
Well , asyouknow, 1'vebeendeliberatelyshakingmy
handatsomemeetings. lf Iwasn'tdevelopingthismore
accurateandcompassionateapproachtomyselfthen
Jo/7n:
ldefinitelVwouldn'tbehavelikethatbecausel'dstillbe
terrifiedabout rejectionandhumiliationandall that
otherstu什lusedtoworryabout.
Ｓ
４Ｊ＆
ｐ
●ロＪ〃
ｅ
旧
ｍ
︐
AnythingeIse？
ｎ
わ
ｍ
lalwayshadthesimpieviewthatyouhadtobestrong
tobesuccessful .NowI realizethatweaknesses,vul‑
nerabilities,beingstrongandsuccessfulcanallbepart
ofthesameperson−me.SoI'vebeentellingsomeof
myfriends, theoneswhothinkl'matowerofstrength
atall times,aboutmysocialphobiaandthat l'mhaving
therapyfor it.They'reamazedtohearabout it. Iwouid
neverhavedonethatbeforebecauselhavebeenso
worriedthat theywouldseemeasweak.Nowthey
canthinkwhattheylike.SoIreallyamchangingforthe
be廿er,noquestionaboutthat.
777elap/Sr
That'sqoodnewstohear｡
曹
Whenclientshavelittleconvictionintheirnewbeliefs, it
canbeverydifficultforthemtoextractanypositiveinformationfromtheirdailyexperience;therefore,thetherapist
needstobealertineverysessiontohelpthempinpointany
evidencethatsupportstheirnewbeliefs.
HistoricalT巳stoftheNewCoreBelief
Maladaptivecorebeliefsareusuallyformedinchildhood
andbythetimeclientscometotherapytheyhavegathered
93
こ．Ｑのユミコ垣延の望曽﹃ざ﹃ざ︒即コミの⑰︑ごａ︒︒﹃①国里荷貯
John:
一両こめ旨之殉ミ謡Ｑ画句塁ト①ミ﹄Ｅｑｏｏ
alotofevidenceovertheyearstosupportthesebeliefs;
however, thisevidenceofone'slifeisaproductofbiasgeneratedbythenegativecorebelief・ Itcanbeproductiveand,
attimes, strangeforclientstoviewtheirpastthroughthe
lensofthenewcorebelieftofindsupportingevidencefor
it.Theclient'slifeisdividedintotimeperiodsIforexample,
childhood, schoolyears) andanhistoricalsearchiscon‑
ductedineachperiodtounearthsupportinginformation.
WhenanhistoricalexaminationofJohn'snewcorebelief
wasconducted,hisfirstportofcallwashisschoolyears:he
pinpointedhisacademicsuccessandthefriendshipshehad
madewhichhelpedtocorrecthisnarrowfocusonbeingner‑
vousandwantingtocrywhenhewas 'inthespotlight' , sayl
bemgsingledoutbytheteachersforcriticismorpunishment.
"deskyandGreenbergersuggestthat ｣itisnotnecessaryto
identifymanye"eriencesthatsupportthenewschemalcore
belief];evenafewaremeaningfultoclients. Ideallyi clients
findoneortwoe"erienCesperagePeriod' ￨1995: 150).
Thesethreemethodsforchangingcorebeliefshelped
Johntoweakenhisconvictioninhisoldmaladaptivebeliefs
andstrengthenhisconvictioninhisnewadaptivebeliefs
IseeBeck, 1995forfurtherwaysoftacklingandchanging
corebeliefsI.
TheCourseofJohn'sTherapy
Johnspentatotalofeightsessionsintherapy・Tbwardsthe
endoftherapyI sessionsweretaperedofftofortnightlyi
thenmonthl)zDuringthecourseoftherapy, Johngradu‑
allyassumedmoreresponsibilityforsettingeachsession's
agenda,identifyingproblemsandfindingsolutionstothem
anddesigninghomeworkassignments; inotherwords,he
wasbecominghisownself‑therapistwhilethetherapist
reconceptualizedherroleasaconsultantorcoachlteaching
clientstobetheirowntherapististheultimateaimofCT
thoughnotallclientSwilltaketoitasreadilyasJohndidl .
94
Johnhadachievedhisgoaloffacinganddefusinghis
fearswhile 'inthespotlight' throughexposureexercises,
learningcompassionateself-acceptanceofhisvulnerabilitiesandpayingattentiontowhatwasactuallygoingonat
committeemeetingsinsteadofrelyingonhisinternaland
distortedrepresentationsofthesemeetings,particularlyin
thefirstfiveminuteswhenhewassigningdocuments.
case,whatifhishanddidshakeuncontrollablyatameet‑
inglitneverhaddonesofar)?Johnsaidthatthisprospect
nolongerscaredhim: ノIfithappens/ I'l1letitpasswithout
sayinganything,makeajokeaboutitorjusttellpeoplel've
hadabaddayorsomething. Itreallyisnolongerabigdeal
inmymind'.
InsummarizinghisexperienceoftherapyJohnsaidthat
thecruciallessonhehadlearnedfromtherapyoccurredin
thefirstsession: ｣I'dbeenlookinginthewrongdirection
formanVVears.Howcanleradicatenervousnessfrommy
character？Theideathatlcouldlearntomanagemyner‐
vousnessbOthconstructivelyandcompassionatelywasan
eye‑opener.Oncelgraspedthatideaeverythingelseabout
dealingwithmyproblemjustfellintoplace'.
Follow‑upappointmentsofthree, sixandtwelvemonths
werenegotiatedtomonitorandprovideencouragementfor
JohIYsprogressasaself‑therapist (sometimescalled'booster
sessions' ); ifheencounteredanydifficultieshewasunable
todealwith､henJohncouldarrangeadditionalappoint‑
mentswiththetherapist.
Uptothispointinthebook,wehavelookedatcognitive
therapyfromassessment, throughtreatmentandthento
95
写員の﹃雪言い遅いのミヨ頁ざ．ゆ刀匡荷い四コＱｏ９の︑里耐討
Inthelastsessionoftherapyrelapsepreventionwasdiscussed, identifyingfuture,post-therapysituationsthatcould
triggerthereactivationofaclient'soldproblems｢anddevel‑
opingplanstocopeconstructivelywiththesesituations
lessentially, employingthetoolsandtechniquesofcogni‑
tivetherapythattheclienthasalreadylearned). InJohn's
terminationbyfollowingthecaseexampleofJohn. Inthe
nextandfinalchapter,wediscusssomeofthewaysthat
helpclientstomaintaintheirtreatmentgainsaftertherapy
hasended｡
Notes
1
gripofhercorebeliefthatsheisafailure｡
２
−両瞳の冒乏応ミ語旦侭芯曇ト①ミ廷臣国︒︒
UnderlyingbeliefscanbeaddressedwhileworkingattheNATslevel
asthelatter$chipaway'attheformerbyprovidingsituation‑specific
evidencethatbeginstoquestiontheirvalidity, forexample,aclient
startstoseethattherearesomesituationswhereshedoesperform
successfully; thisrealizationbeginstoeasethepreviouslypowerful
lt isinterestingtocomparecognitivetherapy'sgradualistapproach
touncoveringandexaminingunderlyingbeliefswithanothercogni‑
tiveapproachcalledrational emotivebehaviour therapy(REBT)
(Ellis, 1994)whichfocusesonrevealingcorebeliefsearlyintherapy
uniesscIientsindicatethattheyarenot readyatthisstagefora
$straighttothecore'､rategy(seeNeenanandDryden,2006).
96
Maintaining
識輸。 mTherapy
，溌識
Onceformaltherapyhasendedwiththeachievementofthe
client'sgoalsandherdevelopmentasaself‑therapist,what
comesnext？Inordertomaintainhergainsfromtherapyl
hercognitivetherapyskillsneedtobecomeawayoflife｡'
Achievingagoalisnotthesameaskeepingit, forexample,
stoppingsmoking,thenstayingstopped; gettingfit,then
remainingfit. Inourexperience, someclientsquicklyslip
backintotheiroldproblemsonce therapyhas ended
becausetheytaketheir 'eyeofftheball'‑theystopprac‑
tisingtheircognitivetherapyskills.Thismayoccurbecause,
amongotherreasons/clientsbelievethatnowtherapyisover,
theirhard‑wonchangeswillmaintainthemselveswithout
anyfurtherinputfromthem; thattheydeservearestafter
alltheirhardwork; orthattherapywasadiscrete, crisis‑
drivenepisodeintheirlifethattheycannowthankfully
forgetabout.Suchideasoftenresultinclientsexperiencing
alapselpartialreturntoaproblemstate)orrelapse(complete
returntoaproblemstatel.Ourmessagetoourclientsis
simple: continuingimprovementmeanscontinuingeffort
fromthem(NeenanandDryden,2002a) .
Themessageoflifelongself‑therapyneedstobecom‑
municatedtotheclientbeforeformal therapyends.The
therapistcansaysomethinglikethistohisclienttoinitiate
adiscussiononthissubject: 'Howwillyourprogressbe
maintainedafteryouleavetherapy？Whatdoyouseeyour
roleasinthisprocess?'Clientsusuallygraspwhatisrequired
ofthemandputitintotheirownterms:aclientwhoworked
asanelectriciansaidhewouldcheckhis 'cognitivewiring'
regularly;anotherclient,afitnessinstructor,saidshewould
remembertoalsokeepherselfin'psychologicaltrim'; in
otherwords,monitoringanddealingwithanyre-emergence
ofself-defeatingthoughtsandcounterproductivebehaviours.
Beckll995Isuggeststhatclientscanconductself-therapy
sessionsinmuchthesamewayasformaltherapy: setan
agendawhichmcludesreviewmganyhomeworkundertaken,
currentorpotentialproblemsthatneedaddressing,designingnewhomeworkassignmentsandsettingthenextdate
foraself-therapysession.Thefrequencyoftheseself-therapy
sessions Iweekly,monthlylhalf-yearly)willdependonthe
client'srateofprogress, soweeklysessionsiftheclientis
■
︸司逗２コ三町ミ当Ｑ応﹄の塁ト①Ｅ廷屋画︒︒
slippingbackintodepressionovertheendofarelationship,
oreverythreemonthsiftheclientwantstoreviewand
fine-tunehisprogress.
ExtractingtheMostValuable
ldeasandTbchniquesfrom
Therapy
Noteverythingclientslearnintherapywillbeperceivedby
themasequallyvaluable.Attheendoftherapy, theycan
summarizeonacardwhattheyconsidertobethemost
valuableideasandtechniquesandkeepit inasafeand
handyplacelikeapurseorwallet.Thiscardcanactasa
remindertoreinforceprogressanddealwithanysignsof
slippingback.Forexample:
'Thoughtsandbeliefsarehypotheses,notfactsI.Thisidea
helpedtheclienttorememberthatcallingherselfa'failure'
wasaself-created, self-defeatinggroundlessassumption,
notanestablishedfact: ノMybehaviourmayfailattimes,
butlneverfailasaperson'.
'Ialwayshaveachoicehowlreacttoevents; theevent
doesn'tcontrolme'.This ideaenabledtheclientnot to
98
overreacttocriticism: 'Whenlwasunfairlycriticizedby
mybosslcouldfeelhurt, likelusedto! orallowherthe
righttobewrongaboutmeandthenputmysideofthe
story,whichiswhatldid'．
・Abdominalbreathing.Thistechniquehelpedtheclientto
calmhimselfdowninstressfulsituations・Placinghishand
onhisstomachandthenbreathingmoredeeplyandslowly
reversedhisshallowandrapidbreathing: ｣Assoonaslget
mybreathingundercontrolandfeelmorerelaxed, Ican
seethesituationinamoreobjectiveway'.
・Detachedmindfulness. Thistechniqueteachesclients to
Theclientsaidhelikenedthetechniquetowaitingatatrain
station: 'Iseethetraincomingin/whichistheoldthought
thatl'museless!butldonitgetonthetrainandwaveatit
asitleavesthestation.Gettingonthetrainwouldmean
Ibelievethethought'.
ActionPIans
Actinginsupportofnewadaptivebeliefshelpsclientsto
strengthenthemandcorrespondinglyweakentheiradherencetooldmaladaptivebeliefs.Thinkingbutnotactingin
newwaysmeansthatlittlesubstantialchangewilloccuror
besustained.Apreparedactionplan｢basedonthework
doneintherapyandreadytohand,helpsclientstotackle
head‑onthereactivationoftheiroldproblemsor, ideally,
moveinquicklywhentheearlywarningsignsofthisreac‑
tivationaredetectedifamilVandfriendscanbeinvolvedin
q
全
thisdetectionprocess) . Someexamples:
q』
AclientnoticesheisbeginningtogettensewhenliStening
tosomeonewhoseviewshedisagreeswith;thistenseness
usedtosignalthatatempertantrumwasimminent‑'Stop
99
ミ亀ミミミコ心︒聖﹃耐弓◎ヨコ扇可動ロ寅
letunpleasantorintrusivethoughts {'You'realoser｢}pass
throughtheirmindwithoutchallengingorbelievingthem.
talkingshit'-andthenhewouldstormoutoftheroom.
Nowtheclientpractiseshisrelaxationexercisesand,more
importantly,hiscommitmenttofreespeech!'Idon/thave
tolikeoragreewithwhathesays,butit'shisrightto
sayit',andstaysintheroomnotonlytoheartheperson
explainhisviewsbutalsotodisagreewithhim.
･Areformedlflexible‑mindedlperfectioniststartstofret
againaboutthequalityofherworkl'1t'snevergood
enough'landmissesdeadlinesforthepresentationofher
work.Missingdeadlinesisthetriggerforhertorefocus
andactonhernewbeliefof'goodenough':qualitywork
producedanddeliveredwithinadeadline.
＝
･Aclientstartstofeel 'clingy'againwithherpartnerand
．
friendsasoldfearsofbeingaloneandunlikedresur‑
face; shedecidestospendtimealonetoremindherself
:
thatshedoesenjoyherowncompany: '1t'snicetobe
E
likedbyothers,but ldon'tneeditfromthem'・ Such
behaviourhelpshertorestoreherfaithinherselfand
の
こ
の
応
■＝
当
Q
図
｡
proveagainthatherrelationshipsaremoreenjoyable
①
whenthe'clinginess' isremovedfromthem.
肯
､ミ oAwifepointsouttoherhusbandthatheisstartingto
廷
営
画
O
C
broodagainovermakingmistakes ('Ishouldhaveseen
thatonecoming.I!manidiot').Herobservationhelpsto
pullhimoutofhislowmoodandtongue‑lashingandinto
notingwhathecanlearnfromhismistake: '1can'tavoid
makingmistakesbutlcantrytomakefewerofthemI．
oAclientfeelshotandlight‑headedwhilestandingina
queueandhasthesuddenurgetorunoutoftheshop一
'1'mgoingtoPanic! '.HeresiStstheurgetorunandtells
himselfforcefullythatnothingcatastrophicwillhappen,
I1t'sjustafewpanickysymptoms' theywillpassina
fewminutesiflkeepcalmandeverythingwillreturnto
normal‑iustasitalwavsdoes｢.
ユ
Clientscanbecomeveryadeptatspottingandimmediately
correctingoldbadhabitsofthinkingandbehaving.Aclient
whorealizedshewasbeingunusuallyquietatameeting
lOO
quicklyprobedforthereason-'Theymightnotlikemeif
Idisagreewiththem'-andspokeupto'slapdown'herold
beliefs: 'I1mnotgoingtocensormyselfinordertobeliked
orgodownthatpathagain'.
ActingasaRoleModel
Theskillstheclienthaslearntfromovercomingherprob-
lemscanbepassedontoherfamily,friendsandcolleagues
iftheyarereceptivetosuchadvice: theclientteachesher
ratingmarriageinsteadofblaminghimselfforit: ｣Ilearntin
therapytolookatthewholepicture,notjustapartofit'.
T℃achingothersmeanstheclientiscontinuingtoteachher‑
selftheimportantconceptsandmethodsofproblem‑solving.
However, theclientshouldavoidpresentingherselfasa
ﾉknow‑all'orparagonasthisismorelikelytoalienateothers
ratherthanencouragethemtolistenandlearn.
Pursuinglmportant
LifeGoaIs
Surprisingasitmayseem/ cognitivetherapyskillsarenot
justusedforovercomingpresentproblemsandtackling
futureonesbutarealsoemployedintheserviceofambitionandrealizingimportant lifegoals IseeNeenanand
Dryden,2002b).Obviouslytheseproblemshavetobedealt
withfirstsotheVdonot interferewiththeachievement
oflonger-termgoals.Forexample,whenaclientrecovered
fromadepressiveepisodehedecidedthe 'timewasright'
tomoveintoself-employmentwhichwasalong-heldambition.Helistedhisworriesaboutself-employment, suchas
financial insecurityandcold-callingtosellhisservicesto
localbusinesses, anddevelopedanactionPlantotackle
101
雪亀ミミミ﹃喝○亀﹃扇寺◎ョ三の３四℃国
friendtoexamineallthefactorscontributingtohisdeterio-
them: tolimithisfinancialexpenditureasmuchaspossible
andnottopersonalizeinevitablerejectionsfrombusinesses
forhisservices I'Theydon'twantmyserviceswhichisfair
enough,butthey'renotrejectingme'l.
Atal2-monthfollow-upappointmenttomonitorhisprogressfollowingtherapyl theclientalsotoldthetherapistof
hisprogresstowardsachievinghisgoalofself-employment:
'Iknewitwouldn'tbeeasy.Businessisonlyatrickleatthe
momentbutl'mpreparedforthelonghaul'.
HowJohnMaintainedHis
＝
GainsFromTherapy
の
こ
§John,ourclientwithdiscretesocialphobia, listedhismost
之
:valuablelessonsfromtherapy:
こ
■−
EL 'Managemynervousnessinsteadoftryingtoeradicateit
m
里
①
§2
＞
g
.3.
o
Q
･民
frommycharacter'.
↓Stopmind‑reading. Let thocommitteemembersthink
whattheywantaboutmeormynervousness'．
'Relaxmyselfbeforesigningthedocumentsanddon'trush
signingthem'.
John'sactionplanwasto'moveinearlyassoonaslstarted
tofeelanxiousaboutbeinginthespotlightatthemeeting'.
'Movinginearly'meantchallengingandbanishingfromhis
mindtheideathathewasweakifhishandshookorifhe
showedsignsofnervousness: 'inthespotlight'hewoulddelib‑
eratelyshakehishandtoremindhimselfofhis'sowhat?'atti‑
tude.Heeventuallyphasedoutthehand‑shakingstrategyas
hesaiditnolongerservedanyusefulpurposeforhim.
Thestrengthofhisnewbelief, 'I'macompetentperson
withvulnerabilities' ，wasputtothetest inaSuddenand
unexpectedwaywhenherealized,minutesbeforehewasto
maketheopeningaddressatthecommittee'sannualgeneral
102
meeting,thathehadleftthetextathome: 'Iwentslightly
wobblyandwishedlwassomewhereelse.Alleyeswereon
me:themembers, theirwivesandhusbands, invitedguests.
Iwas inthisnewspotlight. Igot throughit thoughby
makingitupaslwentalongwithafewjokesagainstmyself
throwninforgoodmeasure. ItseemedtogodownokayI.
Hispartingcommentwas 'Iflcansurvivethat,thenlcan
surviveanything'.
Inthisbook!wehavedescribedthemainfeaturesofthe
corebeliefs.Homeworktaskswerenegotiatedtotestthe
validityofthesecognitionsanddevelopalternativeandbalancedthoughts,assumptionsandbeliefs.Finally,welooked
atwaysclientscanmaintaintheirgainsfromtherapyas
wellasusecognitivetherapyskillstohelpthemachieve
importantlifegoals.
Note
1
ThatCTskilIsshouldbecomepartofaclient'slifeisanotherwayof
describingrelapseprevention: theclientpreventsor reducesthe
chancesofarecurrenceofhisoriginalproblembykeepingawaichfuleyeonthoseareasofhislifewherehestili feelspsychologically
vulnerabletodepression.Forexample,furthersetbacksinhiscareer
couldreactivatehisoldnegativecorebelief, $I'mafailure'.However,
sincetheendof therapy, thisbelief isheldwith lessconvictiontroublesomeratherthantraumatic-andbytakingcontrolofhimself
inastressful situation(:Setbacksareinevitable;depressionabout
themdoesn'thavetobe') theclienthaltsanypotential sIide into
depressiontherebyweakeningfurtherthecredibilityofhisoldbelief.
103
壹亀ミミミコＱＱミコの弓︒ョ﹃ゴミ母℃言
theoryandpracticeofcognitivetherapy.Weusedthecase
exampleofJohntoillustratehowacognitiveconceptualizationofaclient'sproblemsisdeveloped, thenidentifiedand
examinedkeymaladaptivecognitionsatthelevelsofnegative
automaticthoughtsINAIbl,underlyingassumptions/rulesand
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Index
ABCanalysis25‑7
abdominalbreathing99
actionplans99‑100
activityscheduling61‑2
agendasettingl3‑14
'all‑or‑nothing' thinking3
alternativeexplanationsfor
events48
anger6
antecedents25−6
amdetV2, 8
ユ
5
BeckI"vemory20
cognitivecontent6
hotcognitions42
andsocialphobia22
Asmundson,GJ.G.2
assessmentinCT
ABCanalvsis25‑7
assignmentsseehomework
assumptions/rules,underlying
4−5，29
exammmg
advantagesand
disadvantages
ofrules82‑4
behavioural
experiments812
disobeyingrules84‑5
historicaldevelopmentof
rules84
John'ssocialphobia85‑6
vandityofpersonal
contract82
identifying75
directquestions77
if ． .、 then1 statements76
塁
caseconceptualization23‑5
エ
clientsuitabilityforshort‑term
therapy30
diagnosis21‑3
1ongitudinalassessment28
maintainingfactors27‑8
measures20!31
precipitatingevents24,25
strategiestoavoidactiVating
corebelief24!29
teachingthecognitiVemodel
l8‑20
John'ssocialphobia80‑90
sayings,memoriesand
rnottoes77
shoulds
and
rules29
77
thoughts77‑8
unless…then
statenlents76
Auerbach,A.H.60
automaticthoughtsseenegative
automaticthOughts
autonomousindividual7‑8
treatrnentplan31‑3
underlyingassumptions/
musts
themesmautomatic
Barlow,D.H.41
Basco．M、R，2
Beck'A､T・
anxietyinventory20'31
assumptionsandrules79,
84，94
clientresponsetoNAIb47
cognitivecontent‑sPecifiCity
戸毎
，一/
collaborativeempiricism9‑10
depressioninventoryl4,20
developmentofCT1,2,4
cognitivemodel
teachingtoclientl8‑20
theory2‑9
cognitivetasks60‑1
cognitivetherapy
practicesummarized9‑16
theOrysumlnarized2‑9
cognitivevulnerability7‑8
collaborationwithclient
12−13 47
homework60,63,64
emotlonalreactlons8
'hereandnowfocus1 13
collaborativeempiricism9‑10
homework64
negativecorebeliefs5129
conclusions, jumpingto3
conjunctivephrasing88
numberofsessionsl5
continuum,useof90‑1
尖
corebeliefsIschemasl5‑6,
17，28
developingnew90‑2
historicaltestsupport93‑4
John'ssocialphobia94‑6
positivedatalog92‑3
identifying36,57,75
conjunctivephrasing88
behaviours
downwardarrow
andautomaticthoughts36
exPeriments51‑2'62,81‑2
reciprocalinteractionof6
tasks42161‑2
beliefsandABCanalysis26‑7
bipolardisorder2
BlaCkburn! 1.M.8, 19,48163
technique86‑7
1ohn!ssocialphobia88‑9
Bond!EW.9
sentence‑completion87‑8
John'ssocialPhObia23‑4
negativeassumption24
precipitatingevents24,25
processesformaintaining
Burns!D.D、 11 15'51,60,78
Butler!G.2
strategiestoavoidactivating
caseconceptualizationl2
childhoodexperiences23,84
John'ssocialphobia28
89−90
24，29
Craske,M.G.41
DailyThoughtRecord44,46,
55，58 60−1
Clark,D.M.219
cognitionsseethOughts
cognitivedistortions49
cognitivelevels4-5
recurringthemes76‑7
datalog92‑3
Dattilio,EM.2
109
一コＱ①×
oppositethought
suggestion42
personalitytypes7‑8
relapsepreventiolll6
Socraticquestioningl1,52
BecたA"xieiyImjemoFy20,31
BeChDep7essioJTI"vemo7y7,20
Davidson,K.2,5,8, 13,48163
depression2, 8
activityscheduling61
cognitivecontent6
inventory14
goals
John'ssocialphobia31-2
settinglO-11
9radedtaskassignments62
Greenberger,D、6, 37,38,44
detachedmindfulness99
diagnosis
andcaseconceptualizationl2
andsymptoms21‑2
didacticapproachl9‑20
53
58，74，91，94
guideddiscoveryll‑12,
36−71 52−3
healthanxiety2
doublestandards50‑1
'hereandnow' focusl3
downwardarrowtechnique
homeworkl5! 59‑60
assessingprogress67
John'ssocialphobia67‑70,
78−9186−7
Dryden,W49,66
一両廷２コ之町星雲Ｑ図①ニト①ミ廷匡句︒︒
DSMIV212
71−3
non‑complianceofclient
73−4
Ehlers,A2
non‑linearmodelof
Ellis,A,96
emotionalreasoning3
change66
obstaclestocompletion65‑6
enlotlons
continuumofreactions8
rationale63
in-sessionchanges37-8
relevancetosesslon64‑5
maintenanceofdisorders8-9
reviewing70 1
Self‑helpliterature60,74
environmentandreciprocal
specificity64
mteraction6
tasks60‑2
experiments51-2,62,81-2
exposureexercises40
timefor66
'win‑win' formula63
比αγofNega抑e恥αI"α加刀31
feedbackl4, 60
feelings
differenttothoughtsl9
reciprocal interactionof6
writtencopy66,68
HoPe, 'II2
hotcognitions
behaviouraltasks42
downwardarrowtechnique
78−9
Fennell'M.5,29,59,60
focusl3
Frankl,V:E， 16
imagery40
pinpointing43‑4!57
Friedberg,R.D.44
wvorstconsequencesscenarIo
38
39
gains,maintainingseerelapse
prevention
'if…then
Gilbert,P.4, 17160
imagery39‑40,61
110
statements76
information-processmg
negativeautomaticthoughts
commonerrors3
INAIbl co"r.
model2-4
guideddiscovery36-7
imagery39-40
interoceptiveexposure41
John'ssocialPhobia456
pinpointingNAIb43
recurringthemes76
interoceptiveexposure41
Kennerley,H.60
Kuehlwein'K.T.61
labelling3
suggestmgopposlte
Laidlaw,K.2
thought42
therapist-generated
suggeStions40-1
1anguage,imprecise51
lapSe97
SeecIISorelapse
worstconsequences
lifegoals,pursuinglO1‑2
longitudinalassessment28
Lyddon,W17
scenario38-9
examining47
advantagesand
diSadvantagesof
thoughts49
alternativeexplanationsfor
Mahonev,M. 17
ユ
r
nleasures
events48
useof20
behaviouralexperiments
M加dove7Mood74
51−2
mind‑reading3
John1ssocialphobia28
decatastrophizing49‑50
definingterms51
moods
dOubleStandardS50‑1
andautomaticthoughts36
identifyingcognitive
measuresandscales20
distortions49
reattribution50
reciprocalinteractionof6
self‑helpmanual74
weighingtheevidence
seefzIsoemotions
47−8
John'ssocialphobia27,54‑7
negativecorebeliefsseecore
Neenan,M.49,66
beliefs
negativeautomaticthoughts
(NAI副4, 5,57
eliciting34‑5
negotiationseecollaboration
Nelson‑Jones,R. 10
non‑linearmOdelofchange66
behaviouraltasks42
DailyThoughtRecord
44146
opennesswithclientl2‑13
Ove7｡co"1か19A"xieりﾉ60
Ove7℃o"1i"Dep7essio"60
0ve7commgLowSel/zEsteem60
directquestioning35‑6
emotionalchanges37‑8
e"osureexercises40
111
一コＱ①×
John'ssocialphobia31
j
relapsepreventionco7zr.
PadeskyIC.A.
1ohn'ssocialphobialO2‑3
corebeliefsandassumptions
81
pursuinglifegoalslO1‑2
summarycard98‑9
90，94
典
CToverview2,61 17
NHIb37, 38,44,53,58174
Panicdisorder41
hotcognitions42
晶
戸
paranolab
多
relaxation74
rolemodellO1
rulesseeassumptions
Rush,A､ J､2
personaldomain7
personalitydisorders2,5
safetybehaviours25,28
personalitytypes7‑8
Persons,J.B.34,59,62
phobias2
cognitivecontent6
physiolOgy
Safran,J.D
ユ
一両仁２．乏宛昌畠旦殉﹄の兵括①崖鐘屋画︒︒
reactions8
reciprocal interactions6
positivedatalog92‑3
posttraumaticstressdisorder2
practiceofCTsummarized9‑16
precipitatingevent24,25
problem‑solvingfocuslO‑11
progress, client67
progressivemusclerelaxation74
psychiatricinpatients2
psYchologicalproblems9
些
30
Salkovskis,RM2,9
schemasseecorebeliefs
schizophrenia2
Segal,Z.V:30
self‑helpassignmentssee
homework
self‑helpliterature60,74
self‑therapistl5−16!94'95
maintaininggainsfrom
therapy97‑103
sentence‑completion87
sess10ns
followuP95
numberof15, 30
tape‑recording60
short‑termCT! scalefor30
今
SociqIAvoidα加配α刀〔IDisか
questlonmg
direct35−6,77
guideddiscovery36‑7
エ
Socraticll‑12, 17! 52‑3
rationalemotivebehavioural
socializationofclientl4
therapy96
reality‑testing47
reasoning, emotional3
sociotropicindividual7‑8
Socraticquestioningll‑12,
reattribution50
17，52−3
Stallard,R2
relapsepreventiOnl6,97‑8
substanceabuSe2
strategles
actingasrolemodellO1
actionPlans99‑101
S31
SOci(ZICOg72iriO"S
Qzfes"""αかe31
socialphobia21'22,27
SociqIPJIobiqQ"esrio" αかe31
suggestions, therapist‑generated
40−1
symptomsanddiagnosis21‑2
112
tape-recordingofsessions60
'Ihylor,S.2
terms,defining51
77zeDiqg7fosticα"aSta雄ticql
thoughtsco"t.
reciprocalinteractionof6
ユ
Ma刀況aIo/Mど戒aI
seeqIsonegativeautomatic
thoughts
timelimitsl5,30,66
Disoγαe滝21−2
Tinch!C.S.44
theoryofCTsummarized2‑9
thoughts
ABCanalysis26‑7
advantagesand
disadvantagesof49
treatmentplanforCT31‑3
underlyingassumptionssee
assulnptlons
'unless. ..then' statements76
automatic4,76
catastrophic41,49‑50
feelingscomparedtol9
hierarchicalorganizationof4
hot38,39,40,42,43‑4,78
ashypotheses47‑8,62
oppositesuggested42
Walen,S.R.88
Weishaar,M.E.3,6,8, 161 17
Wells,A、 15! 17, 18,21,38149
worstconsequences
scenario389
Wright,J.H2
一コｑ①×
113