Laying the Foundation for Cognitive-Behavioral Therapy (CBT) Skills

During my professional career, I have held deeply to the belief that all people have the capacity for positive change. I see the role of the substance abuse and mental health counselor as integral to helping clients progress toward positive change. I have been doing workshops for the past 20+ years for counselors, teaching them cognitive-behavioral skills so that they can help clients make changes in their lives. During these years, I have developed and adapted ideas and examples to make the learning process more successful. I’ve developed various handouts for my counselors to use with clients and I use them with my own private practice and clinic clients. When I ask myself “what’s in this job for me?” my reward comes back to the positive feelings I bring to myself as I see clients change and regain the life they would like to be living.

I have enjoyed good success as the author of Global Criteria: The 12 Core Functions of the Substance Abuse Counselor – Fifth Edition, and I have motivated myself to write two workbooks. One is A Rational Workbook for Recovery from Addictions – Second Edition and the other is A Rational Workbook for Anger: Help For Those with a Co-occurring Substance Use Disorder, co-authored with my colleague, Theodore Burns. My goal for writing A Rational Workbook for Recovery From Addictions – Second Edition was to make the process of change as easily understood by the client as possible in a user-friendly workbook. The workbook becomes a journal, a document of recovery.

What makes A Rational Workbook for Recovery from Addictions – Second Edition different from other CBT workbooks or text books on theories and techniques? I believe that this workbook and the counselor skills that go with it lay a basic foundation of understanding for the client, thus increasing motivation for change. As a counselor, your initial sessions with a new client involve some teaching. Ask your client “What are the three things that you control in this life?” You may need to help the client identify all three – one’s own thoughts, feelings and behaviors. It doesn’t sound like a lot, but it is everything.

Next, I orient the client to some basic adult learning principles. Educators learn this – substance abuse counselors usually do not. I make 12 points; one characteristic of adult learners is WIIFM or “What’s in it for me?” I believe that clients change when they can see the “What’s in it for me?”

As substance abuse counselors we deal with client’s feelings on a regular basis. In CBT, I teach the four basic emotions – anxiety, anger, depression and contentment. All other emotions fall under the umbrella of these four basic emotions. I provide activities in the workbook to assist the client in identifying numerous other feeling words, thus expanding and preparing the client to be more aware of emotional feeling differences and to move them from strong, negative, self-defeating emotions to other positive, healthy or rational emotions.

I then provide more activities to help the client identify situations that occur and the emotional response to these situations. I purposefully do not ask, “What makes you feel _________” because that question would not be consistent with CBT principles. Other people or things outside of you do not make you feel; rather it is the thought or belief held by the client that makes him or her feel. I am preparing the client to identify situations and the subsequent emotional reactions to those situations.

Goleman wrote his book Emotional Intelligence in 1995. The five levels of emotional intelligence (EI) make sense not only to me but to many others, including clients. Using the motivational interviewing techniques we learn in our training, a counselor can reference the different levels of EI frequently as a client shares future practice efforts to use the CBT you teach. The five levels are: 1. Knowing our emotions; 2. Managing our emotions; 3. Recognizing the emotions in others; 4. Managing relationships with others; and 5. Motivating ourselves to achieve our goals. This fifth level is the one I find most (if not all) clients strive for.

I find that most counselors do not take a neuropsychology course, yet they do have a basic awareness of left and right hemisphere functioning. Clients know they have a left and right hemisphere and generally have a vague understanding of the role that each hemisphere plays. However, in laying a foundation of CBT skills, I go into detail to explain that the left hemisphere is the world of words and the right hemisphere is the world of non-words. I discuss Freud and his concepts of consciousness and unconsciousness, relating those concepts to the role that the left and right hemisphere plays in a client’s thoughts (left) and beliefs (right). I often get an “Aha” experience when I talk about how the client responds to some events without thinking, thus wrongly reinforcing that “it” made me. I reflect on the role that beliefs, habits, automatic responding and the right hemisphere play in creating negative, self-defeating feelings and behaviors.

Only after I lay this foundation of understanding do I then begin to teach an understanding of basic CBT concepts and principles that we, as counselors, have learned in our theories classes. I teach the ABCs of Albert Ellis while giving examples. I teach the client what’s rational. I teach them to ask themselves the five rational questions and, if they do not answer honestly three of the five as “yes”, that their thought or belief is irrational and it would be a good thing to change irrational thinking or believing to something else that is rational.

I have the client practice, practice and practice some more in writing Rational Self-Analyses (RSAs), paying particular attention to the rational debating or disputing of irrational beliefs. I teach about the IT Monsters and other self-defeating beliefs important to understanding irrational cognitions. I teach an imagery technique called Rational-Emotive Imagery, or REI, again encouraging a lot of practice.

I believe the foundational skills are best taught during individual counseling sessions, and that the practice and reinforcement of skills occurs during the group process. Groups are very important to the learning of CBT skills. Those clients with more time in a program become mentors for newer clients and model better efforts at debating irrational beliefs. The CBT-skilled counselor, knowing that all participants in the group have had the basic foundation skills, can point out common errors. The counselor listens for statements such as, “It made me scared” or “He or she made me angry,” and with the mere comment “It or he made you?” the client learns to self-correct.

In summary, A Rational Workbook for Recovery From Addictions – Second Edition lays a foundation of skills for the client to optimally benefit from CBT. One professor in an addictions counseling training school told me, “Wow. This workbook takes theory and shows my students how to put it into action”.

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