Cognitive Behavior Therapy Applied to the Case of Stan
From a cognitive behavioral perspective, I want Stan to critically evaluate and modify his self-defeating beliefs, which will likely result in Stan acquiring more effective behavior. As his therapist, I am both goal oriented and problem focused. From the initial session, I ask Stan to identify his problems and formulate specific goals and help him reconceptualize his problems in a way that will increase his chances of finding solutions.
I follow a clear structure for every session. The basic procedural sequence includes (1) preparing him by providing a cognitive rationale for treatment and demystifying treatment; (2) encouraging him to monitor the thoughts that accompany his distress; (3) implementing behavioral and cognitive techniques; (4) assisting him in identifying and examining some basic beliefs and ideas; (5) teaching him ways to examine his beliefs and assumptions by testing them in the real world; and (6) teaching him basic coping skills that will enable him to avoid relapsing into old patterns.
As a part of the structure of the therapy sessions, I ask Stan for a brief review of the week, elicit feedback from the previous session, review homework assignments, collaboratively create an agenda for the session, discuss topics on the agenda, and set new homework for the week. I encourage Stan to perform personal experiments and practice coping skills in daily life.
Stan tells me that he would like to work on his fear of women and would hope to feel far less intimidated by them. He reports that he feels threatened by most women, but especially by women he perceives as powerful. In working with Stan’s fears, I proceed with four steps: educating him about his self-talk; having him monitor and evaluate his faulty beliefs; using cognitive and behavioral interventions; and collaboratively designing homework with Stan that will give him opportunities to practice new behaviors in daily life.
First, I educate him about the importance of examining his automatic thoughts, his self-talk, and the many “shoulds,” “oughts,” and “musts” he has accepted without questioning. Working with Stan as a collaborative partner in his therapy, I guide him in discovering some basic thoughts that influence what he tells himself and how he feels and acts. Here are some of his beliefs:
“I always have to be strong, tough, and perfect.”
“I’m not a man if I show any signs of weakness.”
“If everyone didn’t love me and approve of me, things would be catastrophic.”
“If a woman rejected me, I really would be reduced to a ‘nothing.’”
“If I fail, I am then a failure as a person.”
“I’m apologetic for my existence because I don’t feel equal to others.”
Second, I assist Stan in monitoring and evaluating the ways in which he keeps telling himself these self-defeating ideas. I assist him in clarifying specific problems and learning how to critically evaluate his thinking.
Therapist: You’re not your father. I wonder why you continue telling yourself that you’re just like him. Where is the evidence that your parents were right in their assessment of you? What is the evidence they were not right in their assessment of you? You say you’re such a failure and that you feel inferior. Do your present activities support this? If you were not so hard on yourself, how might your life be different?
Third, once Stan more fully understands the nature of his cognitive distortions and his self-defeating beliefs, I draw on a variety of cognitive and
behavioral techniques to help Stan learns to identify, evaluate, and respond to his beliefs. I rely heavily on cognitive techniques such as Socratic questioning, guided discovery, and cognitive restructuring to assist Stan in examining the evidence that seems to support or contradict his core beliefs. I work with Stan so he will view his basic beliefs and automatic thinking as hypotheses to be tested. In a way, he will become a personal scientist by checking out the validity of many of the conclusions and basic assumptions that contribute to his personal difficulties. By the use of
guided discovery, Stan learns to evaluate the validity and functionality of his beliefs and conclusions. Stan can also profit from cognitive restructuring, which would entail observing his own behavior in various situations. For example, during the week he can take a particular situation that is problematic for him and pay attention to his automatic thoughts and internal dialogue: What is he telling himself as he approaches a difficult situation? As he learns to attend to his thoughts and behaviors, he may begin to see that what he tells himself has as much impact as others’ statements about him. He also sees the connections between his thinking and his behavioral problems. With this awareness he is in an ideal place to begin to learn a new, more functional internal dialogue.
Fourth, I work collaboratively with him in creating specific homework assignments to help him deal with his fears. It is expected that Stan will learn new coping skills, which he can practice first in session and then in daily life situations. It is not enough for him to merely say new things to himself; Stan needs to apply his new cognitive and behavioral coping skills in various daily situations. At one point, for instance, I ask Stan to explore his fears of powerful women and his reasons for continuing to tell himself: “They expect me to be strong and perfect. If I’m not careful, they’ll dominate me.” His homework includes approaching a woman for a date. If he succeeds in getting the date, he can think about his catastrophic expectations of what might happen. What would be so terrible if she did not like him or if she refused the date? Stan tells himself over and over that he must be approved of and that if any woman rebuffs him the consequences are more than he can bear. With practice, he learns to label distortions and is able to automatically identify his negative thoughts and monitor his cognitive patterns. Through a variety of cognitive and behavioral strategies, he is able to acquire new information, change his basic beliefs, and implement new and more effective behavior.
Stan lives by many “shoulds” and “oughts.” His automatic thoughts seem to impede him from getting what he wants. What techniques would you use to encourage guided discovery on his part?