Modular Training in Cognitive Behaviour Therapy Skills

conference

Cognitive behaviour therapy, or CBT, has become a core skill set for clinicians in mental health settings. With an increased emphasis on evidence-based practice and a need to provide clients with practical skills to help them manage the challenges they face, CBT strategies represent a basic element of practice.

This set of courses is designed to provide professional therapists with a grounding in many of the most widely-used elements of CBT. It is offered in a modular format comprised of multiple half-day components.

Sponsors and organizers can select from a variety of modules to create a complete program. There is also the option of a followup consultation service in which attendees can share their experiences applying the concepts they have learned, and receive feedback on technique.

Some of the modules in the course are adaptations of other offerings on this site. Each module has recommended readings that participants are encouraged to study beforehand. Most modules use the principles of case-based learning to bring the ideas out of the realm of theory and into the practical clinical world.

Organizers can set up a single program comprised of a set of modules, or can schedule one or more modules at a time spaced over weeks or months if desired.

The topics covered in various modules build to some extent on previous content. In order to clarify this, we have grouped programs by level. We encourage organizers to offer the Level 1 module first, then one or more of the Level 2 modules, before the Level 3 modules.

That said, programs are always re-imagined for each new group. Adaptations are made, and elements of one program are sometimes integrated into others.
Contact me to discuss tailoring a program for your group.

All programs include presentation slide handouts, and most include exercise or handout sheets that may be reproduced with clients.


Level One

Cognitive Behaviour Therapy: Background and Basics

There is an increasing emphasis in mental health on evidence based practice, and no psychotherapy has more extensive research support than cognitive behaviour therapy (CBT). Unfortunately, training in CBT is variable and myths and misunderstandings are common.

  • “CBT is a cookbook approach.”
  • “CBT is cold and ignores the feelings of clients.”
  • “CBT is all about convincing people that life isn’t really all that difficult.”

In fact, well-conducted CBT is extremely individualized, emphasizes opening up to the wealth of emotional experience, and involves coming to terms with the reality that life really can be harsh and unforgiving.

This half-day introductory session is designed to introduce participants to the background, origins, and core concepts of CBT, providing a framework for understanding CBT-based ideas and an overview of the research support. It is more of a “what is it?” than a “how to do it” session, and can serve as an introduction for psychotherapists considering further training in the area, or wondering how CBT-based concepts might relate to their own models of intervention.

The program is well-suited to all staff interested in learning more about this complex and interesting therapeutic approach. We encourage agencies hosting this program to throw open the invitation list to anyone they wish - including volunteers and peer counselors.

Level Two

Behavioural Activation: The Most Essential CBT Skill


Behavioural activation is the term for a set of strategies designed to assist the client in planning change. It is the “therapeutic batter” into which virtually all other CBT-based strategies can be stirred.

We cover the central distinction between Ultimate Goals (the client’s vision of what they would like to achieve) and Immediate Goals (what they can accomplish in the coming week). We cover the idea of envisioning changing perceived problems into goals, and the possibility of beginning the work before one has a clear idea of the destination.

A sequential strategy of working from an Ultimate Goal down to an Immediate Goal is covered and practiced with the group. In table exercises participants simulate therapy encounters with clients and work on applying the concepts of behavioural activation to their own lives.

Common problems in goal setting (including noncompletion, “yes buts”, and active resistance) are discussed and strategies for maximizing therapeutic effectiveness are covered.

Lifestyle Modification: Enhancing the Good Life

When asked what would happen if others mimicked the lives of depressed clients for a month, the clients themselves usually predict depression. Many therapists would agree. Much psychological distress appears to be a normal and expectable consequence of poor diet, erratic sleep patterns, inactivity, an impoverished social life, insufficient valuing of enjoyable activity, and a lack of meaning.

One role of treatment is to encourage a gradual shift to a more sustaining lifestyle through education, problem solving, and goal setting. This module reviews the evidence linking various lifestyle factors to either distress or satisfaction, the recommended practices to enhance function, and ways of working with the client to bring about a more enjoyable life.

Managing the Stress Response: Relaxation and Breathing

Excessive stress is a characteristic of many clinical presentations, and strategies to moderate the stress response can be tremendously valuable components of an intervention. This shortened version of our full day Relaxation Skills Training course limits the presentation to diaphragmatic breathing training and progressive muscle relaxation (PMR).

Participants experience each exercise themselves, and practice PMR in dyads, receiving feedback from partners and, where possible, the presenter. This component can also be offered as two half-days in order to incorporate all of the elements of the larger course. Participants receive audio CD masters of relaxation instructions which can be reproduced for clients.

A full day option is available which includes all content from the Relaxation Skills Training course.

Communication Skills Training

Assertiveness training was one of the earliest components of behaviour therapy embraced by Joseph Wolpe. In this module we adapt our two-day Communication Skills Training for Clients course to fit into the context of the Fundamentals of CBT Program.

The material can be presented in from one to four half-days, with the depth of coverage, number of skills taught, and opportunity for skill practice varying accordingly.

The content includes strategies for teaching clients the differences between assertive, passive, aggressive, and passive-aggressive modes of communication, the barriers to assertiveness, assertive nonverbal behaviour, strategies for nonaggressive opinion-giving, ways to give and receive positive and negative feedback, how to say ‘no’, how to make requests, and strategies to manage conflict situations more effectively.

Fundamentals of Exposure Therapy

Exposure therapy is one of the central tools in the treatment of the anxiety disorders, but it can easily be misused and rendered either ineffective or damaging for the client. This module covers how to introduce exposure therapy to the client using two essential models: The Three Zones of Comfort and the Therapeutic Window.

We also cover the concepts of the generalization gradient and the selection of optimal exposure intensity. The application of exposure therapy in several different types of anxiety is discussed.

Participants work in triads to create an exposure hierarchy for specific cases, and use their own anxiety as a useful model. Strategies for ensuring client safety and troubleshooting problems are covered. This module is an adaptation of the Conducting Effective Exposure Therapy course covered earlier in this guide, and can be offered over either one or two half-days.

The Inner Voyage: Commencing Cognitive Work

Cognitive therapy suggests that our emotions and behaviour are largely the product of an internal representation of reality, not necessarily reality itself. Although most of us perceive reality reasonably accurately much of the time, we all experience “slippage” at times, or focus on only a part of our experience at the expense of the larger picture.

This module discusses how to orient clients to cognitive work using a series of examples and exercises that demonstrate the role of appraisals in everyday life. Participants simulate the rationale in small groups, and the three-column form technique is introduced and practiced. We then work on moving from transitory appraisals to an investigation of underlying core beliefs using the Downward Arrow.

The intent is to enhance the client’s appreciation of how we live every moment in an internal world of interpretations, and to develop an increased awareness of the factors from our own pasts that influence the interpretations we make.

Level Three

Cognitive Reinterpretation Strategies: Module One

Simply becoming aware of our own fallible interpretations can often help to alleviate distress, and in this module we learn how this can happen. But some patterns of thinking need additional work.

This module emphasizes the use of the Cognitive Challenging Form in rethinking distressing situations to come up with more accurate, balanced, or helpful ways of seeing things. The use of this technique will be demonstrated in session, then participants will practice the strategy in dyads using case examples and mildly distressing (but not overwhelming) situations in their own lives.

Common problems in the use of cognitive challenging are covered, and the role of cognitive challenging in objectively difficult situations (e.g., life threatening illness) is discussed.

Cognitive Reinterpretation Strategies: Module Two

This second module on cognitive reinterpretation presents four additional strategies for working with clients, and provides opportunities to observe and/or practice each one.

  • Cumulative Probability involves an examination of the likelihood of a feared outcome (e.g., being fired from a job) that depends upon a chain of events working in sequence.
  • The Behavioural Experiment is a strategy for examining the usefulness of closely-held but potentially restricting beliefs about the self or the surrounding world, and has the intent of revealing an alternative point of view.
  • The Cost-Benefit Analysis is a strategy for weighing the attractiveness of two courses of action, usually where one of the options is a change in the direction of health and the other is a continuation of the status quo.
  • The Paradoxical Cost-Benefit Analysis is a variant form in which only the benefits of the status quo and the costs of the change are emphasized.

Participants practice each technique in dyads using case examples.

Cognitive Reinterpretation Strategies: Module Three

  • This third module on cognitive reinterpretation provides participants with background, demonstrations, and practice in an additional set of cognitive techniques. The Pie Chart Technique is used in many situations involving guilt, blame, anger, and personal responsibility for bad outcomes.
  • Functional Restructuring involves examining the positive intent behind problematic behaviour and thinking, and helping the client maintain the same goal while identifying a more effective method of reaching it.
  • Core Belief Work involves identifying underlying beliefs that apply across many situations, examining the evidence for and against the belief, contemplating the possible advantages to holding painful beliefs, and identifying strategies to activate more fair and balanced beliefs.

Emotional Intelligence: The Secondary Appraisal

Traditional cognitive work emphasizes the appraisal (and reappraisal) of the situation in which individuals find themselves. Many problems arise more from the appraisal of our initial response to the situation - our emotions or our behaviour.

  • “I shouldn’t have felt that way.”
  • “This emotion will drive me insane.”
  • “I was an idiot to have run away.”

This module emphasizes the role of our thinking about ourselves and our emotional states, and provides strategies to reduce distress and enhance healthy functioning by becoming more aware of our thinking in this area. We include a consideration of emotional sensitivity (a primary factor in panic disorder, for example) and the overinterpretation of downward mood shifts.

We also consider the role of emotion and impulse in deciding what to do, and the potential guiding role of one’s aspirations and goals over momentary impulse. Participants work through strategies using case examples and dyadic practice.

This program may also be expanded into two half-day sections, Emotional Intelligence 1 and 2.

Mindfulness as a Cognitive Strategy

Mindfulness is a quality of mental state characterized by presence, awareness, and intention. Its role in optimal psychological states (and its apparent absence in distressed states) has led to considerable investigation in recent years of its potential value in therapy.

In this module, we consider the nature and definition of mindfulness, the relation of mindfulness to traditional cognitive therapy, and several non-therapy-based strategies from different traditions which can be used to enhance mindful living. From here we recommend specific mindfulness activities for use in clinical work, ranging from traditional sitting meditation to activities creating the experience of psychological immersion.

The research evidence on mindfulness is touched upon, and participants have the opportunity to experience and practice several mindfulness exercises.


Training Followup Options

Agencies or health regions can opt to follow up CBT module-based training with strategies designed to enhance the application of the techniques learned. As with the initial training phase, sponsors are invited to work with Changeways Clinic to design a followup program that meets the organization’s needs. Here are a few options:

  • Training plus consultation. The training modules above can be spaced weeks apart. Each meeting can include a half-day module followed by a half-day case consultation meeting. If the training group is large, two or more consultation sessions can be offered, each attended by a subset of the group.
    • Scheduled followup distance consultation. Once training has taken place, a set of followup consultation sessions can be set up to be delivered personally (for settings in Vancouver) or via teleconference or videoconference.
    • One-to-one consultation. Individual clinicians can take part in ongoing consultation by submitting recorded audio of actual sessions to a Changeways Clinic supervisor, who will review the sessions and provide guidance and feedback via telephone consultation.
    • On-demand consultation. Following training, clinicians can be provided the option of calling or emailing Changeways Clinic for case consultation on an ongoing basis. Changeways Clinic records usage of consultation time and bills monthly for this service.
    • In-house followup. A highly experienced CBT clinician already employed by the agency or health region can be designated to conduct individual or group consultation for those who attend the training modules. This option combines the advantages of professional presentation sessions plus the establishment of on-site staff as local experts and supervisors.

Our goal is to create a training system that works for the host organization. Consequently, other options or combinations of options can certainly be considered. Tell us what you need and we will attempt to arrive at a solution that works for your requirements and budget.