导言

Introduction Hello, I am Nina Josefowitz. I have been a psychologist, cognitive behavioral therapist, and teacher for over twenty-five years. My partner in writing this book is David Myran, a psychiatrist who has also practiced and taught cognitive behavioral therapy (CBT) for over twenty-five years. We hope this book will help you start to use CBT in your own therapy practice as well as your own life. While we have written the book together, we decided to mainly use my writing style, and therefore the book is written from the singular first person point of view. Let’s begin with defining CBT. CBT is an evidence-based approach to understanding and treating psychological problems. It is a structured, active form of therapy in which the client’s goals are set in the beginning and are addressed throughout therapy. CBT is based on four fundamental principles:

1. How people understand the world, or how they think, influences how they feel, their physical reactions, and how they behave. This means that clients’ problems can be understood in terms of how their thoughts, feelings, physical reactions, and behavior interact and maintain their problems.
2. Clients can learn to become aware of their thoughts, and CBT interventions can help clients change their thoughts.
3. When clients change how they think, their feelings, physical reactions, and behaviors will also change.
4. Because thoughts, feelings, physical reactions, and behaviors are interrelated, when clients change their behaviors, this will also impact their thoughts, feelings, and physical reactions. CBT was first developed in the 1970s as a treatment for depression (Beck, 1970; Beck, Rush, Shaw, & Emery, 1979). At the time, I was a young graduate student at the University of Toronto, just learning how to be a therapist. The dominant therapeutic orientations were Rogerian, gestalt, and psychody- namic. The focused structure of CBT, combined with actively addressing thoughts, was a completely novel and very exciting approach. I can remember the moment I became a committed CBT therapist. I was about to apply for my first practicum in graduate school. Try to imagine: I am sitting on the bus on the way to the interview, feeling anxious. For some reason, the bus stops for twenty minutes. I realize that I am going to be late and that there is absolutely nothing I can do (at that time there were no cell phones). My anxiety rises. Then…I remember my CBT class from the previous day. I take a deep breath and ask myself, What am I thinking? Well, my thoughts are I will be late; my career is ruined! I will never get a practicum placement, and I will fail graduate school. I start to laugh at myself. Even in my highly anxious state, I knew I was catastrophizing. That was the moment I became a CBT therapist. In the past fifty years, hundreds of studies have examined both the underlying theory as well as the effectiveness of CBT for children and adults of all ages (Beck & Dozois, 2011). Let me give you an idea of the extensiveness of the research. Hofmann, Asnaani, Vonk, Sawyer, and Fang (2012) examined meta-analyses of the effectiveness of CBT. They found that while the research is stronger for some disorders than others, generally CBT has been found to be an effective therapy compared with a placebo or waiting list control group for a great variety of problems, including depression, bipolar disorder, anxiety disorders, abuse of alcohol and drugs, schizophrenia, eating disorders, insomnia, personality disorders, anger and aggression, criminal behaviors, general stress, distress due to a variety of medical conditions, and chronic pain.

How This Book Is Organized You can think of therapy as similar to constructing a building; you need to start with a solid founda- tion. In part 1 we are going to learn how to lay the foundation of CBT. A good foundation consists of obtaining a clear sense of your client’s problems and goals, explaining CBT to your client, and starting to use a structured format. You want a foundation that is waterproof, that will stand up to storms and support a heavy building, which means that even if your client is very distressed and goes through hard times, the early work you do in laying down the foundation will serve you and your client well. The next step is putting up the scaffolding. Without a good framework, you can’t put up the walls and windows. In part 2 you will learn to identify your clients’ feelings, physical reactions, behaviors, and thoughts and create a four-factor model that will provide the framework for understanding your clients’ problems. The final stage in building a house involves putting up the walls, windows, and doors. Good con- tractors take their time; they know that the building needs a solid structure. The same is true in CBT. Part 3 covers cognitive and behavioral interventions. We will focus on a variety of cognitive interven- tions, including examining the evidence for negative thoughts, helping clients take a new perspective, and developing balanced or alternative thoughts. We will also cover three behavioral interventions: problem solving, behavioral activation, and exposure therapy. Finally, in part 4 we look at the complete house. We bring CBT to life with an overview of CBT for two hypothetical clients we will follow throughout the book, Suzanne and Raoul. This final section also delves into core beliefs and their importance in CBT. As you work through the book and start to master CBT concepts and skills, you will be laying a solid foundation you can draw upon to help your clients achieve their goals and solve the problems that brought them into therapy. CBT theory and interventions are relevant to people of all ethnic backgrounds, sexual orienta- tions, cultures, and religions. Throughout the book I have tried to refer to “partners” rather than specify the gender of the partner to ensure that heterosexuality is not assumed. In my own practice I never assume a client’s sexual orientation without first checking. Also, when I refer to hypothetical clients in the book, I alternate the client’s gender with each chapter. For simplicity’s sake, the therapist is always female. CBT sessions follow a specific structure, so I thought it would be helpful if the structure of each chapter in this book mimicked the structure of an actual therapy session. Each chapter begins with a check-in and review of the homework from the previous chapter and then sets the agenda, which out- lines the main focus of the chapter. We then work through the agenda, learning the specific skills covered in the chapter. At the end of each chapter I assign homework, and you are given an opportu- nity to review what you have learned. My hope is that the structure of the chapters will give you a sense of what a structured CBT session is like.

How People Learn The research is clear: to learn a new skill, you not only need new information, but you also need active strategies to help you remember and practice the material you learn (O’Brien et al., 2001). The challenge is how to incorporate active learning into a book. First, if you want to remember something, you need to regularly review. The review can be quick; even spending a minute or two will make a difference. At the end of every chapter is a review section, where you will have a chance to think about what was important to you. In addition, I start every chapter with a quick review of the preceding chapter. Second, research also indicates that actively answering questions and testing yourself helps you remember (Roediger & Karpicke, 2006). At the end of each chapter is a list of the main topics we have covered, and after each topic is a question. Try to answer the questions. If you are unsure of the answers, then go back to that section of the chapter. Third, it is hard to remember what you learned unless you apply the material and practice. The data is very clear: the more you practice, the better you get. There is simply no getting around it—if you want to learn a new therapy skill, you need to practice. Throughout the text I have included exercises that I call YOUR TURN! They are an opportunity for you to practice the concept we have just covered. The answers to the YOUR TURN! exercises are in the appendix. You can download additional exer- cises at http://www.newharbinger.com/38501 (see below). Finally, at the end of each chapter I have suggested homework for you to complete before moving on to the next chapter. This is an opportunity for you to bring CBT into your own therapy practice. I think you will enjoy doing the various exercises.

CBT and You Over the years I have found that applying CBT to my own life has not only helped me cope better with various situations, but has also enhanced my CBT skills. Recent research supports my experience that when we apply CBT to ourselves, we become better CBT therapists (Bennett-Levy & Lee, 2014). Throughout the book I have exercises where I ask you to apply CBT to your own life. Try them; I think you will find them helpful.

Online Materials In addition to all of the content in this book, there is a wealth of reproducible supplemental mate- rial available for you to download at New Harbinger’s companion website, http://www.newharbinger .com/38501. Handouts. On the website, you will find handouts that you can use with your clients, including work- sheets and lists of helpful questions. Exercises. These are opportunities for extra practice and for delving into concepts at a more complex level. These exercises are clearly marked in the book with the icon shown here. Audio files. You can find audio files, including the YOUR TURN! Practice in Your Imagination exer- cises, which are marked with the icon shown here. Video clips. Starting in chapter 2, I have short video clips where I demonstrate the skill we have just covered. They are marked with the icon shown here. We will follow two clients, Charlotte and John, who are a combination of many of my clients over the years. Before watching the video clips, please go to http://www.newharbinger.com/38501 and download the short written overview, Charlotte’s and John’s Psychosocial Histories and Presenting Problems.

Conclusion Throughout our careers, David and I have remained enthusiastic about CBT’s capacity to help clients make practical, helpful changes in their lives. We have found that practicing CBT is often fun and engaging as clients start to make real changes. If you are new to CBT, we think this book will give you a solid start; if you have been practicing CBT for a while, we think this book will help you increase your effectiveness. This book demonstrates how David and I do therapy. All therapists have their own style, and there is clearly no one right way to practice CBT. As you read over the sample dialogues, see if there are ways that we practice that you would like to incorporate into your own therapy style. One last word before you start reading the first chapter: do try the exercises. The reality is if you want to learn something new, you have to practice!