Print     PDF

Therapy Skills: CBT


Skills to be trained

Skill: Graded Exposure Therapy


  1. Relaxation therapy (associated with Classical Systematic Desensitization)
  2. Hierarchy Construction
  3. Exposure Therapy 1
  4. Comprehensive Exposure Therapy Model 2
  5. Imaginal techniques
  6. In vivo training


Relaxation Therapy Dialogue

  1. Introductory Comments
    Explain to client, "this is progressive muscle relaxation, I start with your eyes and progressively we relax all the muscles to your toes. Not all muscles relax at once, so if one set of muscles doesn't relax as well as another don't worry, just look for the overall effect of relaxation. In fact a relaxed attitude is to not try too hard about anything in particular. Your mind may occasionally wander away onto other thoughts, don't worry just bring it back to what I'm saying next. Try to adopt a relaxed sitting position with your head square and upright otherwise you might get a stiff neck. Feel free to adjust your position at any time if it suits you. Remember the secret is to relax in all ways not just your muscles."
  2. Initial lead in
    "So just sit with your legs uncrossed (if they are crossed!) to allow for good circulation and now close your eyes. (Pause) Allow yourself to adjust to the experience of going within, perhaps you can hear the clock ticking and some occasional talking outside but just now letting yourself settle down naturally." .pause.
  3. Head to finger tips (first section)
    "Ok so just begin to relax the muscles around your eyes, they are very fine delicate muscles we rarely think about, just let them relax (pause=p). Ok now just let this relaxed feeling spread upward and over your forehead, as if you could just smooth out the brow muscles. p. let this feeling spread up and influence the muscles in your scalp letting all the muscles in the top of your head relax. p.
    Coming back to the eyes letting these go on relaxing and now letting the muscles in your face relax as if you are having a mental facial, relaxing the muscles around your nose, cheeks and lips. p. And now relaxing the muscles around your tongue inside of your mouth,p. now be aware of the larger jaw muscles, we use them for talking and chewing, the larger stronger jaw muscles, let these fall loose and relaxed.
    p. Now as your breath out just allow the muscles in the front and back of your neck to relax. As you breathe out. p. now breathing out all the tension in your shoulders, biceps, forearms, hands and fingers, as if you could breath out all the tension from your shoulders, down through your arms and imagine it going away from your finger tips" .p.
  4. Chest, Back and Stomache (middle section)
    "As you breathe out relaxing the muscles across the chest.p. and now relaxing the muscles down your back, partly you can feel them against the chair , relaxing the back muscles, as you breathe out. p. Sometimes we knot up the stomache muscles when we are anxious, but right now just imagine them unravelling and becoming smooth and soft and warm, as you breathe out. p. So, relaxing all the muscles now in the middle part of your body." p.
  5. Lower part of body (third section)
    " Now relaxing the muscles from the trunk to your toes, relaxing the muscles in the pelvic floor, the muscles underneath your stomache, the muscles in your hip area and buttocks, as you breathe out, relaxing all these muscles. p.
    As you breathe out imagine all the tension flowing down through your legs, down through the thighs, knees, calves, feet and toes, p. breathing away all the tension away through your toes. p. Allowing the thighs to fall loose as if gravity could let them fall loose and heavy. Left knee relaxing and right knee muscles, left calf relaxing and the right, right down you your ankles feet and toes. We walk along all day on our feet taking them for granted, now letting them have like a mental massage. p. So letting the tension drain down through your legs and away through your toes as you breathe out.p."
    Long pause. Eg 20-30secs
  6. Wrap up words and image influences
    So becoming warm and relaxed all over. Listening to these words to see what words and images nourish you in particular, which ones help you to relax just that little bit more. For example, we think the word quiet is a sound, but letting yourself, feel quiet inside. Feeling quiet and still inside of yourself. p. Feeling warm and secure, p. secure and together in yourself. Feeling together within yourself. Like a still pond that even a leaf wouldn't ruffle the surface of. Feeling still and serene, calm and peaceful, within yourself. Muscles feeling warm and pleasantly heavy as if you've had a relaxing work out or warm bath, just going on relaxing, even more deeply. Enjoying the feelings of relaxation that your experience." Ppppp."Just going on relaxing while I sit quietly here with you".
  7. Coming back to the room
    "Ok now in your own good time and pace, beginning to be aware of your feet on the ground and your body in the chair, just letting yourself be aware of where you are slowly and when your ready just open your eyes and let yourself adjust to the room and the lights overhead. Gently coming back."


  1. Use simple language. Be child like in your simplicity.
  2. Rework the territory using different words.
  3. Be directive like " the muscles around your tongue inside your mouth" This is to discourage the mind wandering and to focus them every now and then and it gives the impression you are right with them.
  4. Repetition is relaxing. Try to avoid monotony but use a nurturing repetitiveness. Relaxation is meant to be caring and nourishing in its effect.
  5. Use pauses intuitively; often it gives them time to catch up if they've got behind.
  6. Use image rich language; use visual images, sounds, feelings, muscle sensations etc.
  7. Relax! They are not worried about the sound of your voice or whether you did a muscle out of order. YOU ARE! Just settle yourself and know that they are enjoying the experience and the attention. Slow yourself down and let the session intuitively look after itself. Better to stumble slowly than rush 'correctly'.
  8. Watch their body language and response. This way you can pace your session to suit the mood
  9. Vary your words and images a little from session to session so they don't get over accommodated to you.
  10. If you have a sleepy client or you suspect they are dozing off. Just occasionally raise your voice on a word or two. Sleeping is not relaxing and is not learning.

Systematic Desensitization

Classical Systematic Desensitization

Objective: To construct a hierarchy of levels of anxiety toward some feared object or situation. It is not necessary to be too obsessional but just to target the major/core features and treat these.

Preliminary Steps

  1. Do your general assessment first. This includes life background other problems present and check for patterns and underlying conditions.
  2. If there is more than one (say phobia), get client to choose priority.
  3. Do a behavioural/functional analysis of the conditions producing fear.
  4. Ask client to identify the situations that produce anxiety.
  5. Construct a hierarchy.

A. Constructing the Hierarchy

  1. Ask what is the situation that is the worst. "Say we were talking about a 10 pt. scale what would be 10 as in terrible anxiety, can't stand it overwhelming and so on."
  2. Write this down and continue asking what else is really scary but perhaps next in order.
  3. Try to aim for a 3 level system eg. High / Moderate/ Low where eventually you can categorize the situations.

Example: Say we are working on a "police phobia" where the person was accosted by a police officer and wrongfully charged. The obvious area might be walking into a police officer or being pulled over by a police car. We can place these loosely in our highest fear group.
Next he says a low fear category would be seeing a security officer when he went to a nightclub. Hence you explore the category of authority, "policing" etc. You should make brainstorming suggestions like "what if it was a picture of a police man what category would that fit into, or a movie or TV programme with a police officer in it. What about "Water Rats" or the general news etc? So you fill out areas to establish not only a hierarchy but also a "feel" for the range of the problem. You certainly should have easy ones on the list that would present little difficulty for them. "What if it was a marshmallow police car that your daughter was eating?" What about a police officer that had come to obviously help you when your car had broken down? What if the police officer was your brother? What about a uniform on its own, a gun, a hat etc. And so on. In each group you should have 3-5 items at least.

B. Treatment Phase Imaginal

  1. Choose an easy category item where success is assured. In fact nearly every step should have a likely outcome of success or further preliminary work is required.
  2. Work out in your own mind what information you need before you start the relaxation procedure. For example you decide to try an image of the police officer on the front cover of his 8yo daughter's book. You check the scenario yourself, imagining that you could get him to imagine himself in his lounge room with daughter sitting on lap, emphasizing safety and normality and that then you will get him to make sure he is relaxed first and then you will ask him to turn the book over and check his reaction. Then if ok you will move to the next level which could be say a picture of a police officer he remembers in his old files when a friend of his graduated in the police academy.
  3. Conduct relaxation therapy with client and explain your procedure that you will relax them and then proceed to the children's book.
  4. Sensory-Feeling Orientation. When turning to the lounge room situation run through the senses of sight, sound, kinaesthetic feeling, and general feelings of being in that room. Its not the bath room what does it feel like to be in your lounge, what can you see, the shapes around you, the colour of your walls, floorings and what sounds are their, is the TV going or your wife or daughter speaking, just listening to the sounds. Only check the obvious pertinent senses or feelings, if for example one was on the beach you could get them to smell the salt air and the sea breeze.
  5. Ideo-motor signalling. Check that they are suitably relaxed and then introduce the scenario (2), stress that they are in control, in the chair and with their own image so, don't imagine anything until, they feel relaxed and in control. "Then picture the book and look at the picture, feeling relaxed, let me know when you can look at the picture, feeling relaxed by raising one of your fingers." (Ideo-motor signalling). When they do, just say good and now we will move onto the next image we discussed.
  6. If they don't raise their finger after 10 seconds or so, (you must wait a little and usually this is all you need to do!), take them back to being relaxed again and try again. Ask what number on the SUDS their anxiety represents and if 8 or more go to a lower item on the hierarchy. If it's a middle order number but still uncomfortable, try the exposure system of forgetting the image, resumed pre-image mode and glance at the book again check the number this time. If the number is decreasing, continue. If there are still problems say, "Keeping your eyes closed, just tell me what is happening at present." Suggest a new procedure or try a lower hierarchy item. Reassure them that, everything is fine and it's helpful to know where in our order we should be. With a highly fearful subject it might be wise to stay with a number criterion close to 1 or 2 so that they feel safe and successful throughout. Common sense is handy here!
  7. Proceed through the hierarchy for about 3-4 items at most (or 20mins). This work is quiet trying and involves a lot of emotional energy so don't overdue it. Finish relaxation therapy and return to normal consciousness and discuss the results.
  8. An additional feature you can consider is to get the person to practice an opposite scene to their feared situation and use this in conjunction with relaxation therapy. For example, is they are very insecure you could get them to practice the "secure feeling" working off of an image they have even from childhood. Or if they were in a helpless situation you could get them to picture a situation where they were highly in command, the "powerful feeling".

Invivo Exposure Phase

  1. Nothing like reality! Here we give homework assignments or trying this out on their own if it seems suitable to do that.
  2. If your company can assist the person, eg driving phobia or agoraphobia you might go with them on these reality assignments.
  3. Invivo experiences should have the same principles as the imaginal, do not take people into situations they can't cope with yet and discuss their progress as you go.
  4. In fact do not take people into situations where they may encounter situations higher on the hierarchy than they have succeeded with in the imaginal phase. This could bring all of your work down.
  5. Often it may be possible to run through the imaginal situation first even if you are for example in the car before taking off into the traffic. Hence you associate a familiar successful (imaginal situation) with the new reality, less predictable situation.

Focus Condition A—PTSD

Exposure Therapy (EX)

There are several approaches to treating PTSD that are rather similar at the surface. Exposure therapy (EX), (see Foa, 2000) is regarded as the best evidence based procedure. Foa concludes that EX is superior to Systematic Desensitization (SD) for PTSD, as the relaxation component does not seem to assist as first thought. Hence the emphasis is on 'longer exposures' to the threatening stimulus. Stress Inoculation Training and Cognitive therapy are also seen as helpful. EX retains the hierarchy of SD but still focuses on the images current at the scene of the trauma or concomitant trauma producing imagery. (E.g. watching violent television programmes which are similar to the assault that may have occurred in reality.)

Working (re-exposing) key symptoms of PTSD

From your diagnostic use of PTSD on a DSMIV basis you will have already got some idea of the key symptoms connected to the traumatic incident. EX process is to basically re-explore such symptoms and events in as much detail as possible. (Sounds, smells, images, actions, touch, pain etc).
This produces the bind alluded to above, that the specificity of the traumatic stimuli creates the fear that the person does not want to face. Sometimes you may get complete refusal to even discuss the incident.

IMCT Model of EX

In IMCT we naturally favour a combination of behavioural processes rather than stay with one model. In particular mixing creative imagery (cognitive component) with the hierarchy of SD and the exposure process. This helps to overcome one of the main drawbacks to EX which is the aversive disinterest (and even non attendance rates) that clients have in the original trauma memories, because of the sheer fear.
We have not found the in vivo (practice in real situations) to greatly improve the effectiveness of the imaginal component alone. Hence, since the practical exercises are very time consuming we concentrate on the cognitive aspect over the behavioural component per se. However, it is always useful to keep this and behavioural experiments in mind for certain cases.

Creative Imagery

The creative imagery is consistent with the imaginal component of exposure therapy yet seems to allay the fear inducing impact of the traumatic stimuli a little quicker. In another sense it give the client an opportunity to progressively work up to the stimuli less traumatically since it disguises the trauma in a less frightening image, even a comical image that associates a more relaxed humorous feeling with the previous raw frightening image. (E.g. marshmallow guns, chocolate spiders, and birds that look a little bit like the person's childhood kitten.)
As indicated above the use of creative imagery is quite powerful. Here are some simple steps but remember that is creative challenge for the therapist and initially ideas may not come straight to mind as one is influenced by the trauma that the client is experiencing.
Creative Imagery process:

  1. Identify the dimensions of the traumatic stimuli eg swooping bird with beak and being black.
  2. Tackle these progressively in your creative imagery. If the least threatening is the blackness then you might start of with a black fluffy cat or black stuffed toy.
  3. If it is the beak then you could consider a creature that is like a bird but doesn't have a beak like a small black, fluffy feathered seal toy (blunt muzzle). This seems like cheating but remember that the idea is to disguise the scary part whilst introducing the fearful elements
  4. Sometimes the person's conscious mind is distracted or amused by the composite image that they forget about the real task at hand.
  5. To tackle the swooping motion you can make it slow at first and disguised within some other object. You might try a creature that has not got the slightest suggestion of flight and is associated with affection by the person. 'Pepe Le Pew' dressed in a feathered black cape comes to mind, but you tell the person he is strictly fumigated! (Use of humour to distract.)
  6. In the hierarchy sense, you can gradually make the object more real. The use of a control box is useful to make this transition.

Control Box Imagery

  1. Specific use of creative imagery is the control box. For example with the bird phobia above you might just tell the person that the bird is a toy one but yes it does swoop, is black and has feathers, BUT you have a control box to make it stop, or go slow or faster. The notion is of a remote control devise that the person has absolute control over.
  2. The control box can be extended in the hierarchy to tell the person that the object has now become real but they have complete control over it. This could be an example of a car approaching from behind the person in their rear view mirror. (Where they have a PTSD over rear end motor vehicle accidents.)
  3. Some people add the idea of it having a destruct button on the control box, where they could blow up or seriously modify the object if they wanted. This can be quite appealing where the person has been attacked. Whilst a little violent they appreciate the humour and it reminds them that this is an image and that they have full control over the process. This could be a button that guarantees the feathers will disappear from the bird immediately they press it, if the person was especially frightened of feathers.

Reassurance Instructions

Another low-key technique here which can be used in addition to the creative imagery or at any point in the EX process is to reassure the person, verbally that they have control. Examples are:

  1. "Just remembering that these are images in your mind, there is no real bird here and you are in a safe place in the consulting room". OR:
  2. "And this is just an image in your mind that you choose to picture, you could think of anything else if you chose, like a beach or a car but you choose this image, so you are in total control." OR:
  3. "Just sitting in the consulting room, in the chair, with me, picturing these images that could never possibly hurt you, in a totally safe place and in full control".

The effect here is to 'ground' the person into the current reality situation and to take them away from the consuming fear that the stimuli may have in their mind and in fantasy. Used sparingly and with good timing such phrases can have a huge effect.

Exposure Therapy Comprehensive Model

An extension of the EX model previously mentioned can be formed via the following comprehensive procedure. You can also use previous techniques with this remember all is integrated in IMCT!

  1. Education RE: PTSD eg Chapter 2 Herbert and Wetmore (1999).
  2. Managing hyper arousal techniques and lifestyle adjustments (devising a plan for positive self care during recovery)
  3. Telling the story
  4. Baseline & ongoing monitoring of symptoms
  5. Recording flashbacks
    • triggers
    • intrusive memory
    • Action taken with client
  6. Dealing with flashbacks
  7. Exposure therapy
    • Brief Exposure and then
    • prolonged exposure
  8. Assimilation & finding value
  9. Cognitive restructuring if called for:
    • Exaggerate the NAT
    • Ask, "What's wrong with what I just said?"
    • How do you think I (or another valued person would think about this?)
    • Cognitive restructuring re depression, guilt shame or anger.
  10. Consider the issues of letting go/forgiveness/acceptance:
    • Step back from condemnatory ruminations ("If you want to bury your enemy, dig 2 graves")
    • Behavioural experiments re acting forgiving or getting on with living a good life ("the sweetest revenge")
    • Loving kindness meditation or equivalent

(Paper prepared by Brian Johnston, PHD, 2006, CTAD, Thebarton, S.A.)

Basics of Cognitive Therapy—History

  1. Thus far we have reviewed a behavioural technique called Systematic Desensitisation. This would be an example of the B of CBT. We now turn to the C (cognitive) aspect of the therapy.
  2. The pure behaviourist position regarded that an S-R (Stimulus-Response) was sufficient to explain behaviour. Ellis (1957) agreed with the Greek Stoic philosophers like Epictetus who said: "Men are disturbed not by things, but by the view which they take of them". Ellis would rightfully be regarded as the first contemporary Cognitive Therapist.
  3. Hence, this position produced a long overdue paradigm shift in psychology; that it was not Stimulus that caused Response but that the organism (O) intervening in between. (S-O-R)
  4. Still Behaviourist approaches held sway until the late 1970's until Beck (1979) produced his important work Cognitive Therapy of Depression. Although Beck had contributed in research as early as the 60's it was this work that seemed to seriously bring CBT into vogue over "BT".
  5. Seligman's work Helplessness (1975) had struck a chord with many researchers and clinicians in that people may have learned to be helpless by the events of life and formed corresponding cognitions to create a depression.
  6. Beck succeeded where Ellis had not because he combined a clear replicable 'package' of techniques. He also produced, with others significant research to validate his approach. Beck combined coherent guidelines on the behavioural techniques (Eg Activity scheduling, Mastery and Pleasure Techniques, Graded Task Assignments, Behavioural Rehearsal, Assertive Training and Role Playing). He provided parallel cognitive procedures such as Automatic Thoughts identification, Reattribution Techniques, Recording Dysfunctional Thoughts and Assumptions Underlying Cognitive errors.

Cognitive schedules and Techniques used in IMCT

  1. In IMCT we use the standard schedules initiated by Beck. In the triple column technique we compare the procedure of Ellis with that of Burns, 1981. (First table following this section).
  2. In the next schedule we visit the original Assumptions that Beck advocated as underlying cognitive errors. The Ellis contribution using 'shoulds and musts' is added to this table.
  3. Following then is the 7 columns cognitive restructuring table, which is a modification of Beck's to suit our training purposes.
  4. We then have the modified downward arrow technique of Wells (1997) on our triangle format and dual column procedure.

Triple Column Though Record Compared With Ellis' ABC Technique(R.E.R.)

(*Ellis "A" Activating Event)
**Negative Automatic Thought (NAT)
(Ellis "B" Belief System)
(Ellis "C" Emotional Consequence)
Applies to the situation that appears to upset person. Does not need to have much time paid to it except to elicit the thoughts and feelings that follow **Negative Automatic Thoughts- central theme rapid thoughts or images occurring outside awareness, but triple column process can assist to 'distil' such thoughts into awareness Often the feeling is more useful for obtaining 'the thought' as the client will obtain the 'NAT' in discussing the feeling. (Triple column does not mean client has to remember feeling then thought nor thought then feeling-be natural with it)

*(Ellis's ABC theory was that it was the Belief (B) that was causing the Consequent behaviour/emotion (C) and not the activating event (A). For Belief you can substitute 'cognition'.)

Cognitive Distortions

Below is a list of typical cognitive errors as indicated by Beck (1979). The notion is that there are consistent types or errors that clients make such that you can classify some of them in this way and look out for them. *Also included is the offering of Ellis (1961), in regard to 'musts and shoulds'.

OvergeneralizationIf its true in one case, it applies to any case which is even slightly similar.
Selective abstractionThe only events that matter are failures, deprivation, etc. Should measure self by errors, weaknesses, etc.
Excessive responsibilityI am responsible for all bad things, failures, etc.
Predicting with insufficient evidenceIf it has been true in the past, then it's always going to be true.
Self-referencesI am the centre of everyone's attention- especially my bad performances. I am the cause of misfortunes.
CatastrophizingAlways think of the worst. It's most likely to happen to you.
Dichotomous thinkingEverything either is one extreme or another; (black or white; good or bad).
*Musts, shoulds, got to, have to. (Ellis, 1961)Implies power is outside of the person (as if written by God). As if person had no control over situation/is helpless or 'commanded'. Encourage to shift to 'I choose to, like to, prefer to or I will' statements.

Seven Column Thought Re-Evaluation Table (Cognitive Restructuring)

SituationDefinitive Feeling associated with Negative Automatic ThoughtNegative Automatic thought (Nat)
Belief in (0-100)
Evidence Supporting NatEvidence Against NatAcceptable
Realistic Thought (Art)
Belief in (0-100)
New Feeling from considered
(General Situation only)(This should be the most troublesome feeling/experience that alerts client to wanting to change "the Situation")(Hot thought or core thought associated with definitive feeling)(Evidence from client that supports Nat. This is unchallenged by therapist.)(Evidence that client considers is against the Nat. This is offered by them and not usually by us)(It is wise to concede some negative/'realistic' component here.)(New feelings that follow from all considerations.)

Downward Arrow

Thought Tracing Triangle
(Downward Arrow Process)


  1. Consider the illustration of the downward arrow triangle above.
  2. The advantage of a triangle is that it infers a downward, deeper feeling via a picture. Hence we might consider the question mark at the base as "the shark underneath".
  3. If you think of the Triple Column Procedure except dropping the 'situation column' you have lhs representing the thought and rhs representing the corresponding feeling. Thought 'A' goes with consequent emotion/feeling 'A'.
  4. Thought 'A' might be "I'm presenting my seminar topic". Feeling 'A' might be "stupid/embarrassed.
  5. This might proceed to thought 'B' "I'm a loser"/feeling "inadequate", to 'C' "I can never do anything right"/feeling "hopeless" to 'D' "What's the point to living"/feeling "desperate and worthless". The question mark might be the likely conclusion of I "I should kill myself".

Client procedure

  1. Draw triangle with client, explaining relationship between thoughts and feelings and your desire to progressively reach worse thoughts and feelings that may underlie their problems via a 'thought trace'.
  2. Start with thought 'A' and associated feeling and then use key questions to elicit the next thoughts, even pointing to your "dual column" sheet, (next page); to the parallels with the triangle picture. Eg. "ok now what is a worse thought that comes" or "what do you conclude from that" or "so in what way is that worse for you- a worse way you think about this deep down"?
  3. Continue down the sheet until you seem to have the worst thoughts or the major themes.


Dual Column Technique

Dual Column Technique Worksheet

Guided Discovery/Socratic Dialogue

Key words: Corners 1,2,3, enquiry intervention, therapeutic intervention, challenging skills (advanced empathy, confrontation, immediacy), language skills, and solution paths.

    1. Guided Discovery and Socratic Dialogue are used in conjunction and interchangeably. In terms of our counselling model they are an interweaving between counselling corners one and two and three. Some times you are finding information and others you are reflecting and offering empathy and solution paths.
      Wells (1997), states that Socratic Dialogue (SD) can be used as Guided Discovery (GD).
    2. Socratic questioning seeks to "probe the thinking of another person" (Paul and Elder, 2001). Socratic thinking seeks to understand the foundations for what is said or believed. The attempt is to follow the implications through to further questions. ("Can you explain the reasons behind this fully so I can better understand? Or—"On what do you base these beliefs?" Treat all assertions as connecting points in a network of thoughts.
    3. GD uses such questions in order to help the client discover that they may well have a solution inherent if they follow various implications through. "So if we could find a way of proving that you had ability at making conversation, you seem to say that this would help you a great deal. You say that just talking to your male friends is not proof of this can you tell me a little about the reasons that talking to women must be different to this?"
  1. Basically one is combining 'enquiry intervention with therapeutic intervention'. One wishes to lead via the questioning process to a point where the client is able to 'discover' from their own 'guided' observations that they have thoughts, beliefs or behaviours that could be modified and from within their own resources. The sophisticated insights gained are alike to corner three counselling skills of Egan. (eg advanced empathy). The difference is that you enquire into the persons experience via questions within a cognitive set of parameters.
  2. Clients are not so much having their beliefs 'changed' as they are prompted to examine and change their own beliefs. Hence the term "discovery". Mostly one is using good opening questions to explore the client's experience. The therapist has a sense of where this may go but keeps these hypotheses suspended in case the client doesn't go in the direction suspected. So GD is almost like 'flexible directing'.
  3. Good language skills are in use also. Skills you have already been introduced to and will see more of in psychotherapy skills. One explores the meanings of key words. An astute body therapist will know to cue in on key semantics associated with pertinent body language.
  4. So if you imagine you are doing counselling from corners 1,2 and 3 but with a cognitive framework in your head (hence all 4 corners!) and with advanced empathy style intuition you are equipped to do GD and SD. You counsel the person to explore meanings behind their behaviours and beliefs. You assist the client to uncover these beliefs and examine them with good questions. The client can discover from within their own repertoire where there are pros and cons to these but also advantageous ways of thinking or behaving in other ways, possible for them but previously outside of awareness. It is nothing more than astute counselling.

Focus Condition B—Panic Cycle

The panic cycle as described by Wells (1997) is conceived as sensation-thought-emotion-sensation-thought-emotion. A panic is like fireball wildly fuelling itself into an explosion of uncontrollability. A physical sensation like a tightness in the chest is misinterpreted cognitively, which fuels the escalation and creates more intense emotions which produces increased physiological symptoms like heart beat or tingling in the hands or faint feelings and this produces "further evidence" that something catastrophic is occurring and this increases adrenaline and sweaty palms and muscle tightness lowered ability to think straight and so on.

(From Wells, 1997)


Hyperventilation is producing a rate of breathing which is in excess of the body's needs at this time. Overbreathing, (10-12 breathes per minute is normal); decreases the carbon dioxide in the blood stream. This produces alkalinity in the blood. The CO2 level combined with the increased alkalinity produces most of the physical changes experienced during hyperventilation. (This is the theory behind the idea that breathing into a paper bag—to increase the CO2 levels again.)
Specifically, these effects cause a loss of blood flow to some parts of the body (eg to the brain, resulting in dizziness, light headedness, breathlessness, blurred vision and feelings of unreality.) In the peripheral tissue areas there is also less blood flow resulting in numbness and tingling in the extremities, cold clammy hands and stiffness in the muscles. (Source, Andrews et al, 1994)
The following set of steps is clinically useful when delivered in a language that the client understands.

Panic Attack Treatment


  1. Education continues during this process but is especially helpful early. Start by explaining the previous details of what causes hyperventilation and the panic attack process. It is especially important to start with the sensations experienced.
  2. Mention that it is a perfectly sensible process involving chemicals in the body and can be produced at will (see later for symptom induction). The problem is that the client is producing the process accidentally/habitually.
  3. Show them the panic cycle diagram or draw it on the board. That is that there is a sensation that they attend to in their body, which is different to a feeling, it's a body sensation. They then attribute to this cognitively eg I might panic, a thought that of course from CBT we know causes anxiety as a feeling, but the body then responds to this fear and the person breathes faster increases the body sensations which provides 'evidence' that they may well be about to have a panic, which increases the thoughts and so on.
  4. It is good to be authoritative with this information. Continue by telling them that if they can control the breathing back to normal then the oxygen/co2 levels will stabilize and their body will cease with these sensations. Inform them that they can break the cycle in two ways. Firstly by a breathing process to gain a physiological control and by cognitive techniques to gain thought/feeling control.
  5. Explain that these processes will NOT work for a period of time eg 2-3 minutes because there are numerous chemicals in circulation and their body is a physical object and by sheer inertia cannot slow down instantly even though they can think instantly.
  6. It is useful to watch out for the belief as to whether they think the process is 'medical' or 'psychological'. Strangely here the physical sensation can mean to a client that something is wrong with their body eg heart attack. They do not believe its psychological viz that it is caused by the process of their own habits. This language can be very deceptive, especially as we are also saying to them it's a 'physical process' i.e. overbreathing! When the client begins to believe this is 'psychological' in the correct sense then they make fast progress. This can be accelerated by little experiments like symptom induction. (See below)
  7. Combing the procedure with homework exercises like behavioural experiments is very useful. Behavioural experiments are where the client confronts say a safety behaviour (see below), in order to demonstrate, for example, if staying in doors actually reduced his fear of having a panic. Usually they are concerned with challenging a belief with an enacted behaviour.


This is the notion that they can count a number say 3 on the in breath, hold that for 3, breathe it out for 3 and hold that for 3. (This number might vary for the individual usually 3,4 or 5). They are not trying to deep breathe but normal breath. Remember that fast deep breathing could lead to overbreathing again! It is useful to educate the client into breathing into their diaphragm and not just the chest area, which leads to shallow breathing and hyperventilating. Square breathing gives them something to busy their minds with (hence it is behavioural) instead of focussing on their body sensations. It gives them something to believe in (hence it is cognitive) and it does slow down their breathing back into a normal pattern.

Cognitive Therapy

Identify the cognitions that they are having and teach new ones. Point out the theory of cognitive therapy and that they can be lowering their anxiety with realistic notions. A lot of the psycho-education is cognitive but they can particularly be intervening in their own thoughts even with basic slogans like "I can't shallow breathe and normal breathe at the same time. If I continue to square breathe I will calm down, this will take some time". Or, "this is a normal physical reaction to shallow breathing I can slow it down".

Symptom Induction

If the patient has been cleared by the GP for this procedure if is an ideal exposure procedure for producing rapid belief corrections as to the cause of the panic. (A patient to be wary of is one who has a heart condition!).
Symptom Induction here is the deliberate reproduction of the hyperventilation conditions in the clinic (and best shared by the therapist) whereby the patient can see that the very same conditions are produced purely by deliberate shallow breathing.
It is very useful to rate their beliefs as to how much they believe this is 'physical' or an indication of a medical disorder or psychological (self produced). This should be done before and after. You should be very aware of the key sensations that they are terrified of and get them to check the progress of these. Symptom induction usually needs to be replicated several times often with different cognitions and realizations by the client. It is useful to ask guided discovery type questions like "so what do you think caused the tightening in the throat today" (after the induction). Or "how do you think the light headedness was brought about now?"

Safety Behaviours

These behaviours sustain the cycle. For example a man may seek out lots of hospitals to run to in the event he may panic. A woman avoids therapy because she feels less anxious by staying home. Many safety behaviours lower the anxiety on a short-term basis but spoil the effective recovery from exposure to the reality situations that would facilitate recovery.
Some safety behaviours unwittingly confirm 'data' for the client as in a social phobic person who avoids conversations and people truly ignore him because they think he prefers to be left alone. He confirms that people don't want to talk to him.

Case Conceptualisation

The therapist identifies the symptom cycle as indicated in the panic cycle and relate the safety behaviours that sustain the problem and in later sessions will derive the general beliefs and assumptions usually after the panics have subsided. Hence Case Conceptualising is the therapist's hypothesis as to what causes and sustains the panic cycle. This conceptualisation may be modified over sessions and updated. This can be equally done on an idiosyncratic basis for hypochondriasis, social phobia, OCD, and so forth. Hence the Panic Cycle is in itself a case conceptualisation.
On the following page there is a full diagrammatic page of how the panic attack could be written in full as a case conceptualisation. (From Wells, 1997)

Panic Disorder Conceptualisation

Panic Disorder Conceptualisation Worksheet

Checklist Summary

  1. Use Counselling as your basis and this will elicit the emotions and hence the cognitions.
  2. Begin with Guided Discovery to gently draw connections with thoughts, feelings and interconnections that the person may find acceptable. (Ideas/solutions come from their framework.)
  3. To explore implications more thoroughly and visually use Downward Arrow. This will draw out beliefs and assumptions.
  4. Get client to indicate most troublesome thought or belief.
  5. Look for Cognitive Distortions.
  6. Work on the 7 Column Sheet (or similar), using evidence for and against to perform cognitive restructuring.
  7. Use behavioural experiments to test out certain beliefs.
  8. Look out for safety and avoidance behaviours.
  9. Consider the use of a daily activity schedule. Get them to rate Mastery and Pleasure as it occurs via the schedule.
  10. Get them to Schedule in Activities (as goals) to extend themselves with respect to goals and problems.
  11. For specific problems consider a hierarchy approach like that of SD or EX to overcome high level stressors.