How Psychotherapy Works


Psychologist Bruce E. Wampold, PhD, answers common questions about therapy, such as how exactly it works and what the research tells us about different types of treatment, including psychiatric drugs.

bruce-wampoldReporters/editors/producers Note: The following “Six Questions for …” feature was produced by the American Psychological Association. Feel free to use it in its entirety or in part; we only request that you credit APA as the source. We also have a photograph of the researcher available to reprint, as well as other experts on this topic.

Bruce E. Wampold, Ph.D., is chair and professor of counseling psychology and clinical professor of psychiatry at the University of Wisconsin-Madison. Dr. Wampold is a groundbreaking researcher and theoretician, bringing the rigor of his training in mathematics and the sciences to understanding psychotherapy. He has published more than 100 scientific articles and is the author of the acclaimed book, “The Great Psychotherapy Debate,” which is a synthesis of empirical research on psychotherapy using sophisticated methods that is situated in a historical and anthropological context. APA spoke to Dr. Wampold about how psychotherapy works and what the research tells us about different types of treatment, including psychiatric drugs.

Q. How exactly does psychotherapy help people?

A. Patients often come to psychotherapy with explanations for their difficulties that leave them feeling that the distress will continue indefinitely. Every treatment provides an explanation for the distress that is adaptive — that is, the patient understands that he or she can do something to improve his or her situation. This leads the patient into healthy actions in that the psychotherapy improves some aspect of their lives, whether it is thinking more positive thoughts, creating better relationships, more appropriately expressing emotions, or enacting other positive changes. The critical aspect is not which treatment a person receives but rather that the patient believes this particular treatment is effective and works collaboratively with the therapist.

Q. You have studied the research data; are you any closer to understanding what makes psychotherapy work, and what might make one type of psychotherapy more effective than another?

A. From my reading of the research evidence and my own research, it seems that the differences among treatments in terms of benefit to patients are small, if not negligible. This observation applies, however, to treatments that are intended to be therapeutic, are delivered by competent therapists, have a cogent psychological rationale, and contain therapeutic actions that lead to healthy and helpful changes in the patient’s life. When such treatments are compared in clinical trials, the typical finding is that these treatments are superior to no treatment or some type of psychological placebo (usually contact with a therapist who responds empathically but does not actively provide a treatment) but that there are few if any differences among the treatments.

However, there are common elements of effective psychotherapies. For example, there are hundreds of studies that show that a purposeful collaborative relationship between a therapist and the patient – what we call the therapeutic alliance – is related to therapeutic progress. This relationship holds for all types of therapy. The therapeutic alliance is critical even in medication treatments for mental disorders. The most important aspect of effective therapy is that the patient and the therapist work together to help the patient reach their goals in therapy.

Q. Some therapists consistently produce better outcomes than others, regardless of treatment and patient characteristics. Can you explain why that is?

A. The most effective therapists know the research and have a dynamic approach to treatment options. The research indicates that effective therapists form a strong therapeutic alliance across the range of patients seen in therapy. They are able to form a bond with their patients, regardless of the patient’s characteristics, and induce the patient to accept the treatment and work collaboratively with the therapist. Effective therapists have an ability to perceive, understand and communicate emotional and social messages with their patients. It also appears that effective therapists are cognizant of patient progress, either informally or through the use of outcome measures, and are willing to address issues that impede therapeutic progress, including the relationship between the therapist and the patient.

Q. Clinical trials have shown that psychotherapy is as effective as psychiatric medications for depression and anxiety without the disagreeable side effects such as weight gain, sleep problems and loss of libido. So why is it that so many people are prescribed drugs first when they are exhibiting psychological distress and psychotherapy second, if at all?

A. It is indeed disturbing to know that, despite the effectiveness and safety of psychotherapy, increasing numbers of patients are being treated with psychiatric medications. The explanation for this phenomenon is complex and intricately woven into the health care system in the United States. First, the pharmaceutical industry spends an inordinate amount of money advertising psychiatric medications to physicians and to the public, resulting in a perception that mental disorders are due to “chemical imbalances in the brain” that can be remediated easily by medications. Second, increasing numbers of mental disorders are being treated in primary care settings and primary care physicians are not trained in or aware of effective psychotherapies, but they are trained to prescribe drugs. Third, psychotropic medications suggest that the problem is biological, which relieves the patient of responsibility for his or her actions. It is simpler to take a pill and go on with one’s life than to accept that changing involves intentional and purposeful work.

Professional organizations and therapists need to promote psychotherapy as an effective healing practice. We have relied on word of mouth, to a large extent — patients who have benefited from psychotherapy are our best advertisement. But we have to be more deliberate and a good place to start is in the training of physicians, who need to understand the importance of behavioral health and psychotherapy.

Q. How do you as a psychotherapist determine when psychiatric drugs are the correct course of action for a given patient? And what is the therapist’s influence when treating a patient who is also on psychotropic medication?

A. Health services are always more effective when care is coordinated. Therapists’ collaboration with primary care physicians and psychiatrists is no exception. Of course, effective psychiatric consultation requires that the therapist be knowledgeable about the disorder and its treatment. There are instances in which psychiatric medication is an appropriate adjunct to psychotherapy — for example, in the treatment of severe and persistent depression, bipolar disorder and some anxiety disorders. There is evidence that effective psychotherapists are often the best judges of when their patients can benefit from a pharmaceutical treatment program and work collaboratively with the patient to get the best response to the medication. Some psychologists are now trained and licensed to prescribe psychiatric medications as part of the treatment.

For the most part, psychiatrists and primary care physicians are not trained to provide psychotherapy and psychotherapy does not fit well into the practices of physicians. However, there are many physicians who work collaboratively with psychologists so that patients can make use of effective psychological treatments. Physicians often are eager to make such referrals or encourage patients to seek psychological help when asked. Patients of primary care physicians who are not aware of the effectiveness of psychotherapy may also seek referrals from friends who have benefitted from psychotherapy or from other sources such as state psychological associations. In any event, from my perspective, behavioral interventions should be the first line of treatment and medications used only when response to the behavioral interventions are not sufficient. Far too many people are receiving psychiatric medications without attention to psychological treatments that might be effective.

 Q. If I were a client seeking therapy for the first time, how would I know if someone is an effective caregiver and is offering appropriate treatment? How long should I expect to be in treatment for a given problem?

A. As a starting point, a patient should ascertain that the psychologist he or she is considering is licensed by the state where he/she practices. Ideally, a patient would have evidence that the therapist is effective — has this therapist helped patients in the past? Because this evidence is rarely available, consumers often rely on word of mouth — the testimonial of friends who have benefited from treatment from a particular clinician. After therapy begins, the best cue is the patient’s experience: Does this therapist understand me? Does the treatment plan make sense to me? Do I believe this therapist will help me? And most important — am I making progress? Patients typically experience a positive response to psychotherapy quite rapidly. If a patient is not making noticeable progress in several sessions, the patient should discuss this with the therapist (and similarly, the therapist should initiate this conversation with the patient if adequate progress is not being attained). Together, a patient and therapist determine when treatment should end and often, this happens relatively quickly. Of course, some problems require longer treatment.

Treatment length depends on the problems or disorder, patient goals, patient history and characteristics, events occurring outside of therapy (e.g., divorce, change in employment status), and therapeutic progress. Evidence indicates that therapy typically is terminated when the patient is functioning adequately. Commonly, psychotherapy lasts six to 12 sessions, with more complex difficulties benefiting from longer treatment.

The American Psychological Association, in Washington, D.C., is the largest scientific and professional organization representing psychology in the United States and is the world’s largest association of psychologists. APA’s membership includes more than 150,000 researchers, educators, clinicians, consultants and students. Through its divisions in 54 subfields of psychology and affiliations with 60 state, territorial and Canadian provincial associations, APA works to advance psychology as a science, as a profession and as a means of promoting human welfare.


Please follow and like us:

Therapy is twice as effective in clients’ native language

Psychotherapy for ethnic-minority clients can be particularly effective if psychologists integrate clients’ cultural values into treatment, according to a recent paper that provides the first survey of culturally adapted mental health interventions.

The meta-analysis of 76 published and unpublished quantitative studies found that therapy for ethnic-minority clients who received services in their native language was on average twice as effective as therapy in English. It also found that interventions designed for a particular culture are four times more effective than interventions designed for multiple minority groups.

“The evidence is now in,” says study co-author and Brigham Young University professor Timothy B. Smith, PhD. “And it is in our opinion no longer justifiable to not adapt psychological interventions for clients of color.”

BYU graduate student Derek Griner and Smith analyzed studies of 25,225 total participants; 31 percent were African American, 31 percent Hispanic or Latino/Latina American, 19 percent Asian American, 11 percent Native American and 8 percent European American or other comparison groups.

Among their findings:

  • Participants with or without a mental health diagnosis were equally as likely to benefit from interventions.
  • The ethnicity of clients generally did not affect therapy’s effectiveness. However, therapy for those with low levels of acculturation was twice as effective as therapy for those with moderate acculturation. Hispanic and Latino/Latina clients with low acculturation appeared to benefit the most-perhaps because they are highly likely to speak a language other than English, be migrants and remain in a lower socioeconomic status, the authors conjecture.
  • Studies with participants who were older tended to be more effective than studies with younger participants-possibly because older adults tend to be less acculturated, and therefore in greater need of adaptations to therapy.

However, the authors note more research is needed on how to evaluate whether therapists are culturally competent and how to determine what specific practices help minority clients succeed. They also call for increased foreign language training for psychology graduate students.

D. Smith Bailey

Further Reading

The meta-analysis was published in Psychotherapy: Theory, Research, Practice, Training (Vol. 43, No. 4).
Please follow and like us:

What passes between client and therapist?


Stephanie M. Cobb imagines three perspectives on transference and countertransference.

Transference has been defined as ‘the client’s experience of the therapist that is shaped by his or her own psychological structures and past’, often involving ‘displacement onto the therapist, of feelings, attitudes and behaviours belonging rightfully to earlier significant relationships’ (Gelso & Hayes, 1998, p.11). Countertransference describes the therapist’s reaction to the client in terms of both feelings and behaviour. Originating in the psychoanalytic tradition, transference and countertransference were once seen as fundamental to successful outcomes in psychotherapeutic treatment. However, over time, the emphasis has gradually shifted toward the ‘real’ relationship between client and therapist and some psychologists have even questioned whether the concept of transference exists at all.

Nevertheless, during the first year of clinical training, my cohort were invited to consider how the transference phenomenon has developed and changed over time. I began to think about how important historical figures in psychology might have talked about these ideas, had they ever met. I therefore invite you to suspend academic expectations for just enough time to enjoy the imagined presentation that follows.

Sigmund Freud
Sigmund Freud was born in 1854 in what is now the Czech Republic. Educated in Vienna, he practised medicine until the late 1880s, before turning his attention to studying the psychological origins of nervous disorders. ‘As an explorer, he was first in his field’ (Lomas, 1973, p.37).

Dr Freud, I’d like to give the reader some idea of how we have come to know about the concepts of transference and countertransference. Can you talk us through their discovery?

Freud: Well, it was actually my colleague, Joseph Breuer, who first documented the transference phenomenon, although he did not name it, in his work with Anna O. She developed intense erotic feelings for him in the later stages of her analysis, and I believe he was rather troubled by them. We were working together on trying to uncover unconscious material from the patient’s past through hypnosis, but we often encountered resistance from those who were fearful of revealing shameful memories. We discovered that such patients were inclined to subconsciously transfer their shameful phantasies onto the analyst. I first used the term transference in my Studies on Hysteria from 1895.

Did you realise the significance of your discovery immediately?
Freud: Actually, at first we all found it rather a nuisance! Having the client’s past relationships transferred onto oneself was a serious obstacle to effective psychoanalysis, and we tried our hardest to avoid it. But as time went on, I found that helping patients relive past conflicts in the present could become vital to the effectiveness of the treatment (Malan, 2004).

Can you explain a little more about how transference works?
Freud: In my view, it is unsatisfied or repressed wishes and experiences from the patient’s past, usually from childhood, that become transferred onto the person of the therapist, revealing the source of their neurosis. For example, they may at times see the analyst as a punitive father and at other times as a seductive lover. If handled correctly, the transference allows patients to re-experience childhood conflicts in the safety of the consulting room. With the help of the analyst’s interpretations, these past conflicts can be worked through to a satisfactory conclusion. Countertransference arises from unresolved conflicts in the analyst’s past and must be guarded against at all costs. Responding emotionally to patients is highly detrimental to the analytical process. In order to give rational interpretations whilst being confronted with such strong emotions as love and hate, one must maintain a professional distance at all times (Nye, 2000).

Some of my colleagues in the psychoanalytic school have subsequently challenged my view of the therapeutic relationship. Carl Jung, for example, sees the countertransference as quite natural and believes that the analyst should be at liberty to share his thoughts and feelings with the patient. For Jung, the transference should be lived through without the need for interpretation and the countertransference is simply an inevitable interaction with it. He published numerous papers in the decades following my death suggesting countertransference can be a useful device in uncovering unconscious dynamics within the patient (Jacoby, 1984).

Melanie Klein
Melanie Klein’s work, in the field of object relations, represents a unique departure from the ideas of Freud. She made a major contribution to our understanding of the internal worlds of both children and adults. A controversial figure, who analysed her own children, she had a profound influence on psychodynamic theory and practice.

Mrs Klein, your ideas in particular have been seen as a direct challenge to those of Dr Freud. How would you respond to that?
Klein: I really never saw myself as opposing Dr Freud’s work, simply developing and extending it to increase our understanding of the workings of the human psyche. However, I did conflict with his daughter, Anna, in the 1940s on the thorny issue of transference.

Can you tell us about your view?
Klein: I believe that infants are capable of forming basic object relations from the moment they are born. Experiences of social interaction from earliest infancy form the basis of the internal world of object relations. This in turn shapes the person’s interaction with the outside world throughout their life. Object relations theorists, such as Winnicott, Fairburn and I, prioritise relationships as the fundamental tenets of psychological functioning rather than the instinctual drives that Dr Freud identified. The transference relationship with the analyst therefore, provides an indispensable insight into the internal world of the patient and brings past relationships to life in the consulting room, even when the analysand is still a child.

Do you agree with Dr Freud that countertransference should be avoided?
Klein: On the contrary. The emotional reactions experienced by the analyst are absolutely crucial to understanding how the patient relates to others. Countertransference allows the analyst to enter the patient’s world and bring the transference into consciousness through interpretation (Grant & Cawley, 2002). Paula Heimann was the first to explicitly state the value of countertransference and did much to alter the general view of it. She asserts that ‘the analyst’s unconscious understands that of the patient. This rapport on a deep level comes to the surface in the form of feelings which the analyst notices in response to the patient’(Heimann, 1950, as cited in Sandler, 1976).

In the classical Freudian view, psychosexual conflicts experienced in the formative years are re-experienced as a result of an unconscious wish to gratify childhood desires. In the Kleinien tradition of object relations, early significant relationships are repeated in therapy, and feelings, emotions and behaviours associated with those relationships are re-experienced in relation to the therapist.

Carl Rogers
From the existential, phenomenological approach, Carol Rogers drew his person centred, non-directive approach. The founder of humanistic psychology gives us another lens through which we can view these concepts.

Mr Rogers, would you share with us a little about your style of working?
Rogers: Certainly. In person-centred work, we try to understand the client’s problems just as he sees them himself. We don’t formulate clients into diagnostic categories. The client is encouraged to believe in his ability to solve his own problems by providing an atmosphere of mutual respect. Gradually a situation develops in which the client can risk revealing more and more about himself, knowing that the therapist will respond calmly and continue to respect him at all times (Lomas, 1973).

Can you tell us your view of transference Dr Rogers?
Rogers: Of course, clients will always experience some positive and negative feelings during therapy sessions. Certainly a proportion of these emotional reactions will be based on past experiences but I don’t believe it is necessary to pay those feelings any special attention (Nye, 2000). ‘Transference phenomena occur in every human relationship’ (Jacobs, 2010). In fact they are so much a part of everyday life that we no longer need elaborate manipulations to bring them out (Lomas, 1973). There is no need for the therapist to make interpretations because if he is genuine, accepting and empathic, the meanings of these feelings will nonetheless become clear to the client. What is more, to describe the therapist’s reaction to the patient as countertransference is ‘unsatisfactory’ to say the least (Malan, 2004, p.131). These reactions may be entirely natural and not transferred from anyone else.

Contemporary forms of psychotherapy
There are several contemporary forms of psychotherapy, which are supported by a substantial evidence base, where concepts comparable to transference have recently been identified. Cognitive behavioural therapy (CBT), for example, has become a powerful player since its emergence in the 1970s. Originally aimed at alleviating anxiety and depression, CBT centres on how thoughts influence feelings and behaviours and how modifying core beliefs can lead to behavioural change (Beck, 1991). CBT has been criticised for its ‘mechanistic’ and ‘technical’ view and for not making use of the therapeutic relationships (Jacobson, 1989). However, very recently transference-like phenomena have been identified in CBT work with clients with complex problems, such as personality disorder, where the therapeutic relationship takes a much more central role (Grant & Crawley, 2002).

Freud: Ah yes, I have heard about these developments. CBT and psychodynamic therapies have arisen from opposing philosophies, but in the 1990s the two traditions came much closer together when cognitive therapists began to accept the existence of unconscious cognitive processes. Schemas, for example, are unconscious ‘cognitive representations of one’s past experiences with situations or people’ which help us understand future events (Goldfried, 1995, p.55). The client may form a ‘person schema’ of the therapist which is influenced by schemas from previous situations. For example, if the client perceives the relationship as one of authority and dominance, then a schema of the parent or teacher may be evoked. These schemas are connected to another concept known as a script. Scripts are schemas that affect habitual behavioural sequences. These can be activated in therapy when the client’s behaviour elicits similar responses from the therapist as he would experience in other relationships in his life. Working with the transference can help uncover dysfunctional schemas and scripts (Grant & Crawley, 2002).

Rogers: To me, introducing the notions of transference and countertransference in cognitive therapies serves only to re-mystify the therapeutic process (Rudd & Joiner, 1997). I would always concentrate on the ‘real’ relationship between client and therapist.

Freud: Even though CBT concentrates mainly on the client’s relationships outside the therapeutic situation, the therapist can still use the transference to observe how the client relates in the microcosm of the consulting room. He can then make inferences about the client’s problems out in the world. This is particularly helpful when working with patients living with personality disorder, who are acutely sensitive to the therapist response (Grant & Crawley, 2002). I hope that future cognitive therapies will develop these ideas to make even more use of the multitude of resources available through the therapeutic relationship.

Mentalisation based therapy (MBT) is just such a cognitive therapy, in which the therapeutic relationship assumes paramount importance and transference work is central to affecting change (Allen, et al., 2008).

Klein: As I understand it, mentalising represents an awareness of the mental states of oneself and others and having the ability to interpret these mental states. For most people this is very much a part of everyday life, but for some, especially those who have suffered early trauma, it is extremely difficult and confusing. While impaired mentalising impacts negatively on clients’ daily lives, enhanced mentalising increases capacity to deal with adversity, such as psychiatric problems. A secure attachment relationship provides an optimal environment in which mentalising ability can develop, and in MBT it is the therapist’s job to provide a secure base from which the client can safely explore painful aspects of their past and present (Allen et al., 2008).

When transference occurs in MBT, the interpretation takes the form of active mentalising of the relationship between client and therapist, carefully linking behaviour to a hypothetical model of the patient’s mind. With clients having limited mentalisation capacities, transference work concentrates on the here-and-now relationship of the consulting room. However, as this capacity increases, interpretation of the current relationship moves into the context of understanding past relationships. Mentalising the transference in this way shows the client how the same behaviour can be interpreted in different ways by different minds (Allen et al., 2008).

Freud: It seems to me that the MBT approach has further developed psychoanalytic ideas about understanding the past through the therapeutic relationship.

Klein: Gestalt therapy and psychoanalysis also agree on several fundamental issues. Both place emphasis on conscious and unconscious conflict and past traumatic experience, they share the concept of internalised objects and identify defensive processes that distort reality (Nielsen, 1980).

Rogers: But gestalt therapy concentrates on the here and now and de-emphasises the transference. When transference does arise, Gestalt therapists use what they call ‘empty chair’ dialogues to avoid transferring past relationships onto the therapist. The client enacts both roles so that unresolved feelings from the past are transferred onto an internal object rather than onto the therapist (Nielsen, 1980).

The terms transference and countertransference are constructs employed by the psychodynamic tradition of psychology to describe a particular aspect of the therapeutic relationship. Even though some other schools, such as CBT, may not employ these particular terms, it has been suggested that analogous concepts do exist. As William Shakespeare famously wrote, ‘That which we call a rose, by any other name would smell as sweet’.

Stephanie M. Cobb is a Clinical Psychologist at South London & Maudsley NHS Foundation Trust


Allen, J.G., Fonagy, P. & Bateman, A. (2008). Mentalizing in clinical practice. Arlington, VA: American Psychiatric Publishing.
Beck, A.T. (1991). Cognitive behaviour therapy: A 30 year retrospective, American Psychologist, 46, 368–375.
Gelso, C.J. & Hayes, J.A. (1998). The psychotherapy relationship. New York: Wiley.
Goldfried, M.R. (1995). From cognitive-behaviour therapy to psychotherapy integration. New York: Springer.
Grant, J. & Crawley, J. (2002). Transference and Projection. Maidenhead: McGraw-Hill Education.
Jacobs, M. (2010). Psychodynamic counselling in action (4th edn). London: Sage.
Jacobson, N.S. (1989). The therapist-client relationship in cognitive behaviour therapy. Journal of Cognitive Psychology: An International Quarterly, 3, 85–96.
Jacoby, M. (1984). The analytic encounter: Transference and the human relationship. Toronto: Inner City Books.
Lomas, P. (1973). True and false experience. London: Penguin.
Malan, D.H. (2004). Individual psychotherapy and the science of psychodynamics. London: Arnold.
Nielsen, A. (1980). Gestalt and psychoanalytic therapies: Structural analysis and rapprochement. American Journal of Psychotherapy, 34(4), 534–544.
Nye, R.D. (2000). Three psychologies: Perspectives from Freud, Skinner and Rogers (6th edn). London: Wadsworth.
Rudd, M.D. & Joiner, T. (1997). ‘Countertransference and the therapeutic relationship: A cognitive perspective. Journal of Cognitive Psychotherapy: An International Quarterly, 11, 231–250.
Sandler, J.J. (1976). Countertransference and role-responsiveness. International Review of Psychoanalysis, 3, 43–47

Please follow and like us:

Empathy and genuineness are important in counselling relationship


Disclaimer: This essay has been submitted by a student. This is not an example of the work written by our professional essay writers. You can view samples of our professional work here.

Any opinions, findings, conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of UK Essays.

It is essential in any helping relationship to have an anticipation for change. In the counselling relationship it presents as Hope. An optimism that something will develop in order to bring about constructive change in the personality of the client in order for them to be able to facilitate positive change in their lives.

As with all processes there may be small events that bring about the necessary transformation. In the therapeutic relationship (alliance), it has been observed that it is often the seemingly unremarkable things, such as the core qualities of the counsellor, which bring about the strongest alliance and therefore, the most change. Qualities that have been identified as: Empathy, a sense of Genuineness and Unconditional Positive Regard for the client. According to Horvath and Luborsky (1993) it is reasonably well documented across a variety of therapies, that a positive correlation does exist between good alliance and successful therapy outcome.

It is important to note that early critical writers were inclined to see the therapeutic alliance more as facilitative rather than directly responsible for change (Horvath, 2006). In 1950, a new perspective on the nature of the therapeutic relationship emerged. This perspective was voiced most powerfully by Carl Rogers. In order to bring about constructive personality change, Rogers (1956) identified what he referred to as the 6 conditions. According to his years of experience, these conditions are essential and sufficient in order to facilitate the process of personality change (Rogers, 1956). His six conditions include for the therapist to be congruent or integrated (genuine), to experience unconditional positive regard, and an empathic understanding for the client. Rogers concludes that outside of these core conditions, none other is necessary in order for change to develop.

It is interesting to note how intertwined these three conditions are. One cannot possibly experience and display empathy without some level of genuineness. Similarly, one cannot feel unconditional positive regard without first having some level of empathy. It all sounds quite simple: be the best care-giving person one can be, be comfortable with the person one is, and in doing so one will facilitate change in another. Yet, anyone who has attempted this, will admit that it is not the most natural state for humans to be in. It requires a greater understanding of the core conditions, a desire to want to exhibit these characteristics, and being able to not only apply them to clients but to the counsellor as well. Therefore, in exploring this area of helping, it is of paramount importance to study these conditions in order to bring about change. Firstly, as people; and secondly, as counsellors.

None of the conditions in the counselling relationship can be meaningful unless they are real. Genuineness is at the heart of every true relationship. In daily relationships, genuineness is displayed by the people whom we feel are not hiding from us or themselves. They wear no masks and are comfortable with who they are and what they are feeling. This in turn makes the recipient comfortable and allows them to be open and honest with that person and more importantly, with themselves. This does not change very much in the counseling setting. A congruent counselor is one who is what he is, during the encounter with the client (Rogers, 1967). The genuine counselor allows the client to meet the true person, not the professional with the paperwork. This includes admitting things to himself or the client that is not observed as ideal psychotherapy. It is also essential to note what genuineness does not imply: The therapist must not burden the client with a running commentary of what the therapist is feeling and thinking. He can, of course, voice appropriately any persistent emotions triggered by what the client is saying or doing.

Being genuine is not an easy task. It involves being aware of one’s own flow of experience and being comfortable with sharing with the client. Sometimes it involves vulnerability from the counsellor’s side which in turn can deepen the relationship. It is a fearsome and fearless exchange between client and counselor and when integrated into the relationship, can create very deep levels of understanding. Appropriately opening the door for unconditional positive regard…

Standal coined this phrase in 1954. It was adopted by Rogers and means that there are no conditions of acceptance (Rogers 1967). More than that, it refers to the counsellor’s belief that the client possesses all the resources necessary for change without the need to change him or herself. Unconditional Positive Regard (UPR) is often misunderstood as meaning to be ‘nice’ to the client (Mearns and Thorne, 1988). To be ‘nice’ is a social ‘mask’ people wear to hide their deeper feelings. Being ‘nice’ all the time will only serve to confuse the client and to foster a false sense of security. It is superficial whereas UPR is most efficient when it arises from a place of depth. Another way of defining UPR is to accept all traits and behaviours in another person without it causing significant harm to oneself. The word ‘significant’ is not added superficially. If one states that another’s behaviour is causing significant harm, then unconditional positive regard cannot exist (Rogers, 1967). In order to display UPR, one needs to be aware of one’s own values, beliefs and standards (Sutton and Stewart, 1997). From there one can evaluate and scrutinise them privately or perhaps confidentially with the help of a supervisor.

The fifth of Rogers’ conditions and the third to be discussed here, is empathy. According to Schafer (1956) relatively little investigation of empathy can be found in the psychoanalytic literature. This is despite constant emphasis on its importance not only in the therapeutic process, but of child development and personal relationships. Consequently, it remains a vague concept, sometimes regarded uncritically as synonymous with intuition or more often, accidentally misunderstood as sympathy. These common misconceptions undermine the importance of usage and association of the concept within the therapeutic alliance.

It is difficult to pin point empathy in a relationship because it is most often not a single response made by the counsellor. Nor is it captured by a series of responses. Empathy is a more of a process than an observable response (Mearns and Thorne, 1988). It is a process of leaving one’s own frame of reference behind and entering the world of the client. To be with the client in their frame of reference and to respond with empathic responses. Note that these responses in themselves are not empathy. They are the result of sharing the client’s journey. The sharing creates the empathy. Rogers (1967) explains it as experiencing the client’s world “as if” it were happening to the counselor. Yet making sure never to lose the “as if’. To be able to sense accurately what the client is feeling without getting caught up in the turmoil of the experience.

Researchers found it much simpler to work with the empathic response than the empathic process (Carkhuff, 1971). If researchers are to study the process, they not only have to take into account the verbal responses of the counselor and how it is perceived by the client, but also the series of interactions that have led up to that response. Importantly, empathy is not a skill or technique acquired by a counselor. It is a way-of-being-in-relation to the client (Mearns and Thorne, 1988).

Many scientists in the 1970s and 80s have voiced their fact-based opinions regarding the therapeutic alliance and the necessary conditions for successful counselling. Gurman (1977) concluded that there is significant evidence supporting the relationship between the therapeutic conditions and the outcome of the counselling. Orlinsky and Howard (1986) maintained that when the core conditions were met, 50%-80% of the number of findings were significantly positive. These results were confirmed by observations made by clients involved in these therapeutic relationships.

Just as evidence is feeding the notion of these core conditions having a positive effect on the outcome of the therapeutic relationship, there is also evidence to the contrary. When these conditions are limited, it causes the relationship to deteriorate (Kirschenbaum and Jourdan, 2005). A popular criticism of this evidence, is that many studies compare counsellors employing only a minimal level of the conditions with counsellors using none. Critics claim that the minimal use of a skill does not necessarily provide good evidence that the skill works. Patterson (1984) argues this point by claiming that if success in the counselling process is achieved by only using a minimal level of the core conditions, then it serves to demonstrate exactly how effective these conditions are. When Stubbs and Bozarth (1994) conducted research that controlled the ‘minimal use’ bias, they were unable to find one study where the conditions were not sufficient for counselling success.

As a result, psychoanalytic, eclectic and client centered approaches have emphasized the importance of the counselor/therapists’ capacity to perceptively and appropriately understand the inner experience of the client/patient. Consequently, the qualities of Empathy, Genuineness and Unconditional Positive Regard have been highlighted as being essential to the therapeutic alliance and subsequently, a positive outcome to the counselling process.


Please follow and like us:

New Voices: Parental alienation – time to notice, time to intervene

New Voices: Parental alienation – time to notice, time to intervene

Sue Whitcombe looks at broken child–parent relationships and the damage they can cause, in the latest in our series for budding writers

At this precise moment I’m in some manic, hyperactive mode that is suppressing my exhaustion as I beaver away at my urgent ‘to do’ list ahead of my Friday flight to Spain. Twelve days. Twelve whole days in which I am banned from using my computer, accessing e-mails and reading anything remotely related to my research – express orders from my 15-year old daughter. I had promised her that things would be different once the ‘conference season’ was over. I hadn’t quite anticipated the knock-on effects of disseminating my research.

My interest in psychology developed from the intertwining of two distinct threads. First, as a teacher of young people with additional needs, learning difficulties and social, emotional and behavioural problems, I became interested in their development, how they learn and barriers to their learning. As I came to know my students better, I found myself in awe of many of them. Just how did they actually manage to get into school with such regularity, considering the difficulties and challenges they faced daily, let alone engage with their learning? Second, I succumbed to a long period of debilitating depression: I had a burning need to understand why.

My journey into counselling psychology took a while longer. To be frank, like many I had never heard of counselling psychology. My recently acquired psychological understanding, my new-found sense of self and experience of personal therapy had changed my relationships with others. Friends and family found me to be supportive, empathic and non-judgemental, turning to me for advice, to sound off or for a shoulder to cry on. A therapeutic role seemed like an option worthy of serious consideration, but I was also keen to maintain my burgeoning interest in research. Then my daughter and I developed a friendship with a father and his similarly aged daughter, whiling away many an enjoyable Saturday together. I was totally unprepared for the devastating fallout of one ordinary Saturday afternoon where I witnessed a minor disagreement between dad and daughter – over a mobile phone and a bicycle. Immediately following that trivial disagreement, this young girl ceased all contact with father; she has refused to speak to or see him for the past three years. Even as a bystander, this experience has had a profound impact on me.

Discovering parental alienation
I thought I knew children and young people quite well. After all, I had three of my own and I had worked with them for 10 years; I understood child and adolescent behaviour didn’t I? So challenged was I by the behaviours I had observed, that I sought to gain an informed understanding. This was when I came across ‘parental alienation’ (PA). The more I read, the more I understood, the greater my shame, guilt and sadness. Shame that I had usually taken what I saw before me at face value and not sought to look deeper; guilt that my ignorance had probably contributed to the alienation; sadness at the growing realisation that there was very little I could do to rectify the situation for this young girl and her dad. Witnessing the devastating repercussions on the lives of people I loved and cared about, motivated me to ‘do’ something. So began my research, my determination to raise awareness of PA and to develop resources and support where little existed – and my training as a counselling psychologist.

Parental alienation is the unwarranted or illogical rejection of a parent by a child, where there was previously a normal, warm, loving relationship. It most often occurs in highly conflicted relationship break-ups and is the result of intentional or unintentional actions, most usually by the parent with care turning their child against the non-resident parent (NRP). Over a period of time, this poisoning effect leads to the child becoming hostile, vitriolic and abusive, usually culminating with the total rejection of the NRP.

This rejection is often the only ostensible solution for a distressed child who is unable to deal with the hostility and conflict between parents. Faced with the cognitive dissonance arising from the imbalance between their own experience and external messages, a child feels compelled to choose between one parent and the other in order to minimise distress and maintain what is needed – stability. This manifests itself in a splitting defence, whereby a child views one parent as all good, and the other as all bad, unable to manage the reality that there is good and bad in both. Once PA has become entrenched it is particularly resistant to remedy other than through the passage of time (Fidler & Bala, 2010).

A pattern of behaviours common to cases of alienation was first described by Gardner (1985) and further refined in later research (Gardner, 2003). Whilst Gardner’s research has been criticised as over-simplified, theoretical and subject to lack of peer review, he did bring the issue of PA to the attention of the legal, mental health and social care professions (Faller, 1998; Kelly & Johnston, 2001; Spruijt et al., 2005). Gardner’s behaviours and symptoms have been further explored and developed and while this research cannot confirm causality, the strategies and behaviours identified are believed by the participants to be alienating (e.g. Baker, 2005; Baker & Darnall, 2006, 2007).

Whilst in the short term children who reject their parent may appear to function reasonably well in their day-to-day lives, the medium and long-term effects can be significant and distressing (Waldron & Joanis, 1996). Evidence suggests that the lifelong effects of losing contact with a parent due to a child’s rejection for no significant reason are substantial. Depression, substance abuse, damaged self-esteem, and enduring relationship issues with lack of trust, divorce and alienation from their own children have been found in adults who experienced PA as a child (Baker, 2005, 2007). Not only do these children have to deal with their belief that their parent was a ‘bad’ person, but the later recognition that they have been forced to exclude a loving, caring, decent parent from their life may cause irreversible damage to their relationship with the alienating parent (Clawar & Rivlin, 1991).

American twaddle?
There are of course perfectly legitimate reasons why a child may reject a parent – as in cases of genuine neglect, physical or sexual abuse, or violence in the home. These cases of genuine estrangement are not covered by PA, which is characterised by a dislike and rejection of a parent for no apparent logical, significant reason.

Whilst the concept of PA is acknowledged and even seen as mainstream in many countries, it remains contentious and continues to be hotly debated as evidenced by the recent deliberations surrounding its inclusion in DSM-5 (Bernet et al., 2010). It is difficult to determine whether the benefits of a diagnosis of such a psychiatric disorder outweigh the risks.  Risk of harm may be further exacerbated due to an increase in parental conflict following such a diagnosis, which might suggest that one parent was to blame for the situation. Such a diagnosis may be counterproductive in the reparation process. However, the absence of PA in nosologies such as the DSM, enables its denial by some, and has been blamed for a lack of research and appropriate resources to support conflicted, separating families and young people.

Although there are hundreds of peer-reviewed articles by psychologists, psychiatrists, legal and social work professionals attesting to the concept and presence of PA in highly conflicted divorce cases, it has rarely been openly or formally discussed in the UK. Anecdotal evidence, and the preliminary findings in my research, suggest that the concept is perceived as ‘American twaddle’ and is most usually dismissed out of hand by the judiciary, solicitors and Cafcass officers when raised in family proceedings, despite clear reference to PA throughout the Cafcass Operating Framework (Cafcass, 2012).

I’ve been immersing myself in the literature around PA for three years now – scouring every journal article, magazine posting, book chapter, seminar, support group and blog that deals with the issue from one perspective or another. I have met with so many parents who have lived with PA on a daily basis – who deal with pain, loss, shame, guilt, anger, rejection, disbelief, depression, sadness, ignorance and judgement. I have met many more counsellors, psychologists, academics, teachers, social workers and lawyers who have never heard of PA. And then there are those people that happenstance dictates I bump into. In polite conversation they ask me why I’m going to a conference, or what I’m researching. After checking out – ‘Do you really want to know?’ (lest I should bore them) – I explain to them what PA is, and what my research is about. It never ceases to surprise and dismay me, the number of times I hear ‘that happened to my son’ or my partner, my daughter or my friend, a colleague.

I feel driven to raise awareness of PA in those professionals who work on a daily basis with those whose lives are damaged by this tragedy. I feel driven to raise awareness in the general public, so that PA can no longer be denied or swept under the carpet in the same way as childhood sex abuse used to be. This lack of awareness exacerbates the alienation process and its impact on children and parents alike.

My decision  to present at conferences this year, and particularly the Division of Counselling Psychology conference in Cardiff, was very much motivated by this desire to raise awareness in professionals who will come across PA in their daily work, yet may not be aware of it. Early responses from participants in my research align with the anecdotal evidence; many parents who have experienced PA are highly critical of their experience with psychologists. I am also keenly aware that whilst encouraging participation in my research by asking potential participants to ‘add their voice’to my study, many are sceptical whether their voice will actually be heard. After all – few people have listened to them or tried to understand their situation to date.

My experience at the Division of Counselling Psychology conference this year was a very emotional and rewarding one. Prior to my attendance, I had been advised that I had been awarded the BPS Division of Counselling Psychology (DCoP) Trainee of the Year prize for my work entitled ‘Psychopathology and the conceptualisation of mental disorder: The debate around the inclusion of Parental Alienation in DSM-5’ (Whitcombe, 2013). I was to receive the award at the conference. What I could not have envisioned was that my poster presentation ‘The lived experience of alienated parents: Developing a Q sort’ would also be judged as best at the conference. Yes, I feel some pride, but my overwhelming emotion is one of validation: validation by my peers and my chosen profession that PA and the experience of parents in this situation is especially worthy of discussion and research.

Presenting at the DCoP conference and then at the PsyPAG conference in Lancaster the following week, I feel that I achieved my objective: the voices of my research participants were heard. It is a small step in the right direction. But then there are also those knock-on effects, the ones I mentioned at the outset, which have found me (under my daughter’s orders) in need of enforced holiday relaxation before embarking on the final year of my doctorate.

Since returning home I have been inundated with e-mails, suggestions and requests; requests for more information about PA; to write articles; suggestions for collaborative research – even an invitation to make representation to a national government. Perhaps the time is just right to be talking about parental alienation. If we fail to acknowledge it, to understand it and start to address it, we are complicit in condemning so many families to a life with limited hope, little support and the lifelong impact of relationship difficulties, mental health problems and a diminished sense of self.

Sue Whitcombe is a trainee counselling psychologist and lecturer in psychology


Baker, A.J.L. (2005). The long-term effects of parental alienation on adult children. American Journal of Family Therapy, 33, 289–302. Baker, A.J.L. (2007). Adult children of parental alienation syndrome: Breaking the ties that bind. London: Norton.
Baker, A.J.L. & Darnall, D. (2006). Behaviors and strategies employed in parental alienation: A survey of parental experiences. Journal of Divorce and Remarriage, 45(1–2), 97–124.
Baker, A.J.L. & Darnall, D. (2007). A construct study of the eight symptoms of severe parental alienation syndrome: A survey of parental experiences. Journal of Divorce and Remarriage, 47(1), 55–75.
Bernet, W., von Boch-Galhau, W., Baker, A.J.L. & Morrison, S.L. (2010). Parental alienation, DSM-V, and ICD-11. American Journal of Family Therapy, 38, 76–187.
Cafcass (2012). Cafcass Operating Framework. Retrieved 8 March 2013 from
Clawar, S.S. & Rivlin, B.V. (1991). Children held hostage: Dealing with programmed and brainwashed children. Chicago: American Bar Association.
Faller, K.C. (1998). The parental alienation syndrome: What is it and what data support it? Child Maltreatment, 3(2), 100–115.
Fidler, B.J. & Bala, N. (2010). Children resisting postseparation contact with a parent: Concepts, controversies and conundrums. Family Court Review, 48, 10–47.
Gardner, R.A. (1985). Recent trends in divorce and custody litigation. Academy Forum, 29(2), 3–7.
Gardner, R.A. (2003). Does DSM-IV have equivalents for the parental alienation syndrome (PAS) diagnosis? American Journal of Family Therapy, 31, 1–21.
Kelly, J.B. & Johnston, J.R. (2001). The alienated child: A reformulation of parental alienation syndrome. Family Court Review, 39, 249–266.
Spruijt, E., Eikelenboom, B., Harmeling, J. et al. (2005). Parental alienation syndrome in the Netherlands. American Journal of Family Therapy, 33, 303–317.
Waldron, K.H. & Joanis, D.E. (1996). Understanding and collaboratively treating parental alienation syndrome. American Journal of Family Law, 10, 121–133.
Whitcombe, S. (2013). Psychopathology and the conceptualisation of mental disorder: The debate around the inclusion of Parental Alienation in DSM-5. Counselling Psychology Review, 28(3), 6–18.


Please follow and like us:

Different Approaches To Psychotherapy

Psychologists generally draw on one or more theories of psychotherapy.

A theory of psychotherapy acts as a roadmap for psychologists: It guides them through the process of understanding clients and their problems and developing solutions.

Approaches to psychotherapy fall into five broad categories:

  • Psychoanalysis and psychodynamic therapies. This approach focuses on changing problematic behaviors, feelings, and thoughts by discovering their unconscious meanings and motivations. Psychoanalytically oriented therapies are characterized by a close working partnership between therapist and patient. Patients learn about themselves by exploring their interactions in the therapeutic relationship. While psychoanalysis is closely identified with Sigmund Freud, it has been extended and modified since his early formulations.
  • Behavior therapy. This approach focuses on learning’s role in developing both normal and abnormal behaviors.
    • Ivan Pavlov made important contributions to behavior therapy by discovering classical conditioning, or associative learning. Pavlov’s famous dogs, for example, began drooling when they heard their dinner bell, because they associated the sound with food.
    • Desensitizing” is classical conditioning in action: A therapist might help a client with a phobia through repeated exposure to whatever it is that causes anxiety.
    • Another important thinker was E.L. Thorndike, who discovered operant conditioning. This type of learning relies on rewards and punishments to shape people’s behavior.
    • Several variations have developed since behavior therapy’s emergence in the 1950s. One variation is cognitive-behavioral therapy, which focuses on both thoughts and behaviors.
  • Cognitive therapy. Cognitive therapy emphasizes what people think rather than what they do.
    • Cognitive therapists believe that it’s dysfunctional thinking that leads to dysfunctional emotions or behaviors. By changing their thoughts, people can change how they feel and what they do.
    • Major figures in cognitive therapy include Albert Ellis and Aaron Beck.
  • Humanistic therapy. This approach emphasizes people’s capacity to make rational choices and develop to their maximum potential. Concern and respect for others are also important themes.
    • Humanistic philosophers like Jean-Paul SartreMartin Buber and Søren Kierkegaard influenced this type of therapy.
    • Three types of humanistic therapy are especially influential. Client-centered therapy rejects the idea of therapists as authorities on their clients’ inner experiences. Instead, therapists help clients change by emphasizing their concern, care and interest.
    • Gestalt therapy emphasizes what it calls “organismic holism,” the importance of being aware of the here and now and accepting responsibility for yourself.
    • Existential therapy focuses on free will, self-determination and the search for meaning.
  • Integrative or holistic therapy. Many therapists don’t tie themselves to any one approach. Instead, they blend elements from different approaches and tailor their treatment according to each client’s needs.

Adapted from the Encyclopedia of Psychology     (

Please follow and like us:

There is no such thing as the true self, but it’s still a useful psychological concept

By Christian Jarrett

“I don’t think you are truly mean, you have sad eyes” Tormund Giantsbane ponders the true self of Sandor ‘The Hound’ Clegane in Game of Thrones, Beyond The Wall.

Who are you really? Is there a “true you” beneath the masquerade? According to a trio of psychologists and philosophers writing in Perspectives on Psychological Science, the idea that we each have a hidden true or authentic self is an incredibly common folk belief, and moreover, the way most of us think about these true selves is remarkably consistent, even across different cultures, from Westeros to Tibet.

This makes the concept of a true self useful because it helps explain many of the judgments we make about ourselves and others. Yet, from a scientific perspective, there is actually no such thing as the true self. “The notion that there are especially authentic parts of the self, and that these parts can remain cloaked from view indefinitely, borders on the superstitious,” write Nina Strohminger and her colleagues at Yale University.

One way that psychologists have investigated people’s views of the true self is to ask them to consider that a person has changed in various ways – either their memories, or their preferences, or their morals, or their personality, for example – and then ask them after which change has the person’s true self most been altered. The results are incredibly consistent: people most consider that the true self has been altered if a person’s moral sense is changed. In other words, most of us believe that the true self is the moral self.  This also manifests in the common reluctance we have to consider taking hypothetical drugs that might alter our moral judgments (more so than our reluctance to take drugs that would alter our personality, for instance).

Related to this, explain Strohminger and her co-authors, is that most of us seem to be biased to see our own and other people’s true selves as essentially good. When a bad person turns good, we see this as their true self emerging. Conversely, if a good person turns bad, this is because circumstances have conspired to constrain or corrupt their true self.

Also, the normal bias most of us have to assume we are better than average disappears when it comes to the true self: that is, we see both our own and other people’s true selves in a similar, very positive light. “It is worth emphasising just how striking this discrepancy is” write Strohminger and co. “One of the most ubiquitous effects in the self literature – actor-observer valence asymmetry – fails to obtain for true self attribution.”

These widespread assumptions that the true self is moral and good is remarkably consistent across cultures: even Hindu Indians and Buddhist Tibetans see moral aspects of a person as especially central to their identity, even though the latter group deny that there is such a thing as the self.

The assumptions we hold about the true self also help explain the judgments we make about other people’s behaviour. For instance, if a person’s emotions lead them to behave badly, we judge them less harshly, presumably because we assume their true self was led astray. Conversely, if a person’s emotions lead them to behave admirably, our praise for them is undiminished, presumably because in this case we assume their virtuous true self was at play.

So the concept of a true self is useful in terms of understanding people’s judgments and behaviour. And we can speculate and investigate why most of us think about the true self in the ways that we do: for example, perhaps we’ve evolved to see the human true self as fundamentally good because assuming the best in others helps foster social ties.

However, on the question of whether there really is such a thing as a true self, Strohminger and her colleagues are sceptical. They point out that views on the true self are highly subjective and skewed by our own judgments of what is good (psychopaths, for instance, see morality as less central to identity presumably because morals are less important to them). Our beliefs about the true self also seem “evidence-insensitive” – claims made about the true self “may completely contradict all available data”. The authors conclude: “These two features – radical subjectivity and unverifiability – prevent the true self from being a scientific concept.”

The True Self: A Psychological Concept Distinct From the Self

Christian Jarrett (@Psych_Writer) is Editor of BPS Research Digest


Please follow and like us:

Is Mindfulness Safe?

The practice of mindfulness has many benefits; how can we ensure it is safe?

The benefits of mindfulness practice are increasingly well documented, but little attention has been paid to potential risks. The prevention of harm to people learning mindfulness skills requires the field to study both the benefits and the risks. We offer the following discussion with the understanding that perspectives may change as research on benefits and risks continues to evolve. We begin with parallels between mindfulness practice and physical exercise, for which the risk/benefit analyses are better understood. We then describe factors to consider in understanding the safety of mindfulness practice and conclude with suggestions for ensuring safety of those undertaking mindfulness programmes, as well as directions for future research.

Physical exercise: benefits and risks

Physical exercise is a popular pursuit. Gyms and fitness classes are everywhere. Books, magazines, and blogs tell us how to get stronger and fitter. Public health campaigns encourage us to exercise more, and wearable devices and apps enhance motivation by keeping track of physical activity. There are good reasons for this enthusiasm. Research shows that exercise improves many aspects of physical and psychological health. It strengthens the heart, lungs, bones, and muscles. It helps people control their weight and manage diabetes and arthritis. It reduces the risk of colon and breast cancer, heart disease and stroke. Exercise improves sleep, increases energy levels, boosts mood, and reduces the risk of depression and the impact of stress. It sharpens thinking and concentration while helping to prevent dementia and Alzheimer’s disease. It increases confidence, self-esteem, and quality of life (Centers for Disease Control, 2015).

Exercise also has significant risks (Garber et al, 2011). People sprain joints, tear tendons, and have painful muscle spasms while exercising. Some suffer from asthma, others from heat stroke or heart attacks. Occasionally these consequences are fatal. Deaths are most likely when people do vigorous activities that they aren’t accustomed to, particularly in hot weather, but sometimes in the cold. Shovelling snow, for example, causes at least 100 fatal heart attacks every winter in the US, mostly in people who don’t realize the intensity of this form of exercise. Not surprisingly, research also shows that working with a well-trained fitness professional reduces the risks of exercise, especially for people with medical conditions.

Experts have reached a consensus that physical exercise, when it’s done carefully, has numerous important benefits and prevents much more harm than it causes. The risks, though potentially serious, can be substantially reduced through consideration of three important factors: the intensity of the exercise, the vulnerability of the person, and the quality of the instruction.

Mindfulness practice

Mindfulness practice is sometimes compared to physical exercise. The analogy is not perfect and the science is at a much earlier stage. Nonetheless, experts often describe mindfulness practice as a form of mental exercise. Regular and sustained mindfulness practices are described as helping to strengthen our attentional muscles and change the way we think and behave.

Like physical exercise, mindfulness practice has become a popular pursuit. Classes, books, magazines, blogs, and apps are widely available. Research shows that practicing mindfulness has many benefits. Although the empirical literature is much smaller than for physical exercise, we have strong evidence that mindfulness-based programmes reduce anxiety, depression, and stress and help people cope with illness and pain (Khoury et al., 2013). Some studies show that the practice of mindfulness increases positive moods and cultivates compassion for self and others (Eberth & Sedlmeier, 2012; Khoury, Sharma, Rush, & Fournier, 2015). It may also improve some forms of attention and memory, although findings are mixed (Chiesa, Calati, & Serretti, 2011). There is also preliminary evidence that practicing mindfulness has measurable effects on the brain (Tang, Holzel, & Posner, 2015).

On the other hand, we have very little scientific information about the potential risks of mindfulness practice. Descriptions are emerging of problems brought on by mindfulness practice, including panic, depression, and anxiety. In some more extreme cases, mania and psychotic symptoms have been reported. These problems seem to be rare, but nonetheless significant, and require further investigation and guidance.

Temporary discomfort versus lasting harm

In psychological treatment research, harm, adverse events and risk are defined as follows:

Harm is defined as a sustained deterioration in a person’s functioning that is caused by the treatment programme (Duggan et al, 2014), or an outcome that is damaging, injurious, or worse than it would have been in the absence of treatment (Dimidjian & Hollon, 2010).

Serious Adverse events are specific occurrences, such as hospitalizations or suicide attempts; they might be caused by the programme, or they might be unrelated to the programme. For example, some patients with severe depression kill themselves during a course of treatment, but this does not necessarily mean that the treatment caused the suicide. In clinical trials, an independent committee evaluates the causes of adverse events and judges whether the events are attributable to the treatment(s) being studied.

Risk is the likelihood that particular adverse events will occur if the programme is undertaken.

Just as physical exercise can cause soreness and fatigue, psychological treatment is often uncomfortable, because it requires psychological and behavioural change, confronting painful experiences, learning new skills, and applying the skills, often in challenging situations.  When treatment is successful, the discomfort is temporary and doesn’t mean that the programme is harmful, but rather that psychological change is difficult.

Unfortunately, psychological treatment is not always successful and occasionally it causes harm. In fact, research consistently shows that 5-10% of clients get worse with psychotherapy (Crawford et al., 2016; Lilienfeld, 2007). In most studies, it is difficult to know why, because participants may have gotten worse with or without the therapy.  However, a few treatments have been shown in randomized trials to be worse than no treatment at all. For example, critical incident stress debriefing (CISD) is intended to prevent post-traumatic stress disorder in people exposed to extreme stressors, but has the opposite effect in some people, possibly because it interferes with natural recovery processes (Lilienfeld, 2007).

Mindfulness practices will bring into awareness experiences that are pleasant, unpleasant, or neutral. It can lead to states of ease, joy, relaxation, peace and a sense of wellbeing. Unpleasant experiences such as agitation, physical discomfort, sleepiness, sadness and anger are also common. Such experiences are usually temporary. The theoretical models that mindfulness draws from state that these pleasant, neutral and unpleasant experiences are part of the normal human experience. Seeing them arise and pass away is part of the learning process (Williams & Penman, 2011).

In people seeking help for stress, pain, or psychological disorders, unpleasant states are more likely to arise because they are part of the phenomenology of these problems. These unpleasant states are considered harmful only if they lead to sustained deterioration or some form of injury. Randomized trials consistently show that mindfulness-based programs are more effective than no treatment. However, it is possible that a small proportion of participants experience sustained deterioration or long-term harm. This question has not yet been adequately studied and is a priority for future research.

Are mindfulness practices safe? How can we safeguard those teaching and learning mindfulness?

Physical strength and fitness are generally healthy conditions that probably don’t cause harm in most circumstances. Harm is more likely to arise through unsafe or excessive forms of exercise. In a similar way, mindfulness is a natural human capacity that appears to be beneficial in many circumstances. Harm is more likely to arise through misguided or inappropriate forms of mindfulness practice. In thinking about how to teach and learn mindfulness safely, we offer three key dimensions: the intensity of the practice, the vulnerability of the person and the quality of the mindfulness instructor/instruction. Understanding these factors will help to ensure that protection against risk is in place for those practising mindfulness and that teachers of mindfulness-based programmes receive appropriate training and supervision.

  1. The intensity of the practice

Some mindfulness practices are very low intensity, such as bringing friendly awareness to the tastes and textures of food, sensations in the body while walking, or sights, sounds and scents while washing the dishes. These practices invite people to orient their attention to their natural capacity for mindfulness in sensorial perception; what they see, taste, hear and touch. There is no evidence that such practices cause harm. In fact, they are likely to help people discern what they like and dislike and what leads to good and bad outcomes. For example, one of us had a participant who every day for years had eaten a particular instant food for lunch. When he brought awareness to the preparation (pouring water onto the dried food and adding a sachet of powder) and the eating he realised he did not actually like the taste, nor did it satiate his hunger.

Low-intensity mindfulness practices are offered in many teacher-led programmes as well as through self-help books, downloadable recordings, and apps. Headspace, for example, provides short, low-intensity mindfulness exercises that are used by millions of people. Headspace was developed by a highly experienced mindfulness teacher and has been researched with attention to benefits and safeguarding, although the evidence to date is still very limited (Bostock & Steptoe, 2013; Mani, Kavanagh, Hides, & Stoyanov, 2015).

Moderate intensity practices are used in mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), and other evidence-based mindfulness programmes. Over 8 weeks, participants sit for up to 40 minutes each day practicing mindful observation of their thoughts, feelings and bodily sensations. They are invited to orient their attention both to the pleasant and the unpleasant. They are asked to bring their new skills and learning to the difficulties that brought them to the class (e.g., chronic pain or recurrent depression). For most participants, especially those with significant physical or mental pain, this will almost invariably bring to mind difficult or unwanted memories, emotions, and sensations. Learning to work skilfully with such experiences, which are understood to be normal, can lead to substantial improvements in mental health and wellbeing. In-session practices are followed by discussion with a mindfulness teacher who helps participants make sense of what they noticed during the exercise. Detailed guidance is also provided for practice between sessions.

Research on serious adverse events and harm from such programmes is just beginning. In trials where the population of clients are well defined and the mindfulness teachers well trained, preliminary research suggests there is no evidence of harm (Kuyken, Warren et al. & Dalgleish, 2016). Adverse events occasionally occur, but have not been attributable to participation in the mindfulness programme. However extensive qualitative research suggests that people do experience difficulties and challenges with their practice, and that learning to manage these difficult experiences can be empowering (Allen, Bromley, Kuyken, & Sonnenberg, 2009; Malpass et al., 2012). In a recent study of chronic low back pain, some participants in both MBSR and cognitive behavioural therapy (CBT) reported that pain temporarily got worse as they began to attend to it and learn to manage it. These increases in pain did not qualify as adverse events. By the end of the treatment programme, both the MBSR and CBT groups had improved significantly more than a group receiving usual care (Cherkin et al., 2016).

The most intensive way to practice mindfulness is on meditation retreats, where participants typically meditate for many hours each day, often entirely in silence, for a week or more at a time. Contact with a teacher may occur only once every day or two. Most reports of adverse effects of mindfulness practice to date come from participants in intensive retreats. The best retreat centres are operated by meditation teachers with comprehensive knowledge of the retreat centre’s orientation (e.g., Christian, Buddhist etc.), extensive experience in offering the teachings in those settings, and knowledge of the difficulties that may arise during intensive mindfulness practice. Teachers at these centres will frame the difficulties they encounter within their own orientation and experience and the best will undertake some degree of screening, have a safeguarding policy and ways of referring to treatment centres when appropriate.  Clearly most retreat centres are not intended to be treatment centres and are therefore not staffed by people with mental health qualifications. Very little research has been conducted on the psychological effects of intensive retreats. Anecdotal evidence suggests that harm is rare, but a few participants have reported severe psychological problems lasting for months or years after the retreat has ended (Rocha, 2014).

  1. The vulnerability of the person

Consensus opinion is that the more vulnerable a person is, the greater the need to attend carefully to when, how and if mindfulness should be taught. Unfortunately, very little is known about why some people are more vulnerable than others to psychological problems brought on by mindfulness practice. Pre-existing mental health difficulties, such as a tendency to experience anxiety or depression, or a history of trauma or psychosis, may increase the risks.

However, recent studies show that even highly vulnerable participants can practice mindfulness safely if their needs are carefully addressed. For example, Chadwick (2005) has developed ways for people who experience psychotic symptoms to practice mindfulness safely; he develops a strong relationship with the person he is teaching and a context of safety, assesses the person’s strengths and vulnerabilities and offers brief, focused mindfulness practices, with a great deal of support through the learning process and adaptation of the teaching based on feedback. Findings are promising, though preliminary. Two large trials of people with recurrent depression suggest that MBCT may be particularly indicated for those with a history of adversity (Williams et al 2014; Kuyken et al., 2015), but in these trials participants were carefully assessed and screened, pre-class interviews oriented them to the MBCT programme and the teachers were well trained and supervised in working with the difficult experiences that almost inevitably come up in these groups. The back pain study mentioned earlier (Cherkin, Sherman et al, & Turner, 2016) reported no serious adverse effects, despite temporary increases in pain during both MBSR and CBT. In combination, these studies are encouraging in suggesting that MBSR and MBCT can be used safely in participants with a variety of vulnerabilities. However, much more research on this question is needed.

  1. The quality of the instruction

Contemplative traditions have long recognized that intensive mindfulness practice can lead to challenging emotional or bodily experiences that require expert guidance. The developers of secular, evidence-based mindfulness programs also emphasize the importance of competent mindfulness teaching. Unfortunately, interest in mindfulness classes has become so widespread that not enough qualified teachers are available. Some teachers have very little training and may be unprepared to help participants with either the normal and expected unpleasant experiences that arise or the more atypical unexpected side effects of mindfulness practice. They may do little screening and assessment to determine if people are suitable and ready for programmes at different levels of intensity. Teacher training programmes are themselves still developing, including with regard to how best to ensure the protection of those learning mindfulness. The field is only just beginning to develop good practice guidelines and listings of qualified teachers. For teaching mindfulness at any intensity (e.g., MBSR and MBCT) and with vulnerable populations, we suggest that teachers must meet these good practice guidelines and ideally be able to independently evidence this by registering on a listing of qualified teachers.

What can we conclude about the safety of mindfulness practice?

Any program with the potential to be therapeutic may involve risk. Ensuring participants’ wellbeing and minimising any chance of harm requires that mindfulness practices are offered with skill and care. Harmful effects of mindfulness practice appear to be rare but have not yet been thoroughly studied. Until we understand the risks more clearly, the wisest course for anyone interested in mindfulness is to begin with low to moderate-intensity practices. Self-help books, recordings, and apps can provide helpful instruction in introductory practices, especially if written or developed by people with recognized expertise. A popular programme is Mindfulness: A Practical Guide to Finding Peace in a Frantic World (Williams & Penman, 2011). This programme was developed to introduce mindfulness in ways that are believed to be safe and engaging and it shows promising evidence of effectiveness.

People interested in more intensive practice should work with an experienced teacher offering evidence-based classes. Those with mental health difficulties should consult with a mental health professional before beginning a mindfulness program, and should only undertake a programme taught by someone who has the training and experience to support them. They should ask if teachers of such programmes have been appropriately trained. Ideally, those in the UK will be registered with the UK Network of Mindfulness-based Teachers.

People interested in the very intensive practice of a meditation retreat should remember that retreats are operated primarily by meditation teachers, rather than mental health professionals, and psychological research to date tells us very little about their effects. It may be wise to consult with an experienced meditation teacher before undertaking an intensive retreat. For people with mental health difficulties it may be wise to consult with a mental health professional with expertise in mindfulness practice. This is especially for those with little experience with less intensive forms of mindfulness practice.

Finally, participants in any form of mindfulness practice should remember three crucial points:

First, mindfulness is not intended to be a blissful experience. Like exercise, it can be uncomfortable. In fact, mindfulness is about learning to recognise, allow and be with all of our experiences, whether pleasant, unpleasant or neutral, so that we can begin to exercise choices and responsiveness in our lives.

Second, mindfulness practice is not a panacea. It’s not the only way to reduce stress or increase wellbeing, nor is it right for everyone. People should select an approach that matches their interests and needs, whether it be mindfulness, physical exercise, cognitive-behavioural therapy or some other approach.

Third, mindfulness practice is intended to be invitational and empirical. Participants are invited to experiment with the practices in an open-minded and curious way and to be guided by the evidence of their own experience, continuing with practices that seem helpful and letting go of those that don’t.

Over the last 50 years, research on physical exercise has provided a large body of knowledge about the likely benefits, the types of exercise best suited to people with particular conditions, the risks of different forms of exercise for different people, and how to minimize the risks. The result is a strong consensus across numerous medical authorities that most people will be healthier if they exercise in particular ways and with care. The mindfulness field has not reached this level of consensus because the research base is not yet sufficiently developed. We need more study of how to match the intensity of the practices to the vulnerability of the participants. We also need clearer information about the risks of mindfulness practices, how to minimize the risks, and how to train teachers to help participants manage the inevitable difficulties. As the field progresses, these questions should be a high priority for research on the effects of mindfulness training.

Ruth Baer and Willem Kuyken


Declaration of interests

Ruth Baer is author of Practicing Happiness: How Mindfulness Can Free You From Psychological Traps and Help You Build the Life You Want and receives royalties from its sales. She is Professor of Psychology at the University of Kentucky and is spending a sabbatical year at the University of Oxford Mindfulness Centre.

Professor Willem Kuyken receives no payment for public engagement or consultancy, and any remuneration is paid in full to the not-for-profit charity Oxford Mindfulness Foundation. He is Director of the Oxford Mindfulness Centre and Principal Investigator of several NIHR and Wellcome Trust grants evaluating MBCT. Willem is Professor of Clinical Psychology at the University of Oxford.


Allen, M., Bromley, A., Kuyken, W., & Sonnenberg, S. (2009). Participants’ experiences of mindfulness-based cognitive therapy: “It changed me in just about every way possible.” Behavoural and Cognitive Psychotherapy, 37,413-430.

Bostock, S. K., & Steptoe, A. (2013). Can finding headspace reduce work stress?? A randomised controlled workplace trial. Psychosomatic Medicine, 75(3), A36-A37.

Centers for Disease Control and Prevention (2015). The benefits of physical activity.

Chadwick, P., Taylor, K., & Abba, N. (2005). Mindfulness groups for people with psychosis. Behavioural and Cognitive Psychotherapy, 33, 351–359.

Cherkin, D., Sherman, K., Balderson, B., Cook, A., Anderson, M., Hawkes, R., … Turner, J. (2016). Effects of mindfulness-based stress reduction vs cognitive behavioural therapy or usual care on back pain and functional limitations in adults with chronic low back pain: A randomized clinical trial. Journal of the American Medical Association, 315, 1240-1249.

Chiesa, A., Calati, R., & Serretti, A. (2011). Does mindfulness training improve cognitive abilities? A systematic review of neuropsychological findings. Clinical Psychology Review, 31, 449-464.

Crawford, M., Thana, L., Farquharson, L., Palmer. L., Hancock, E., Bassett, P., Clarke, J., & Parry, G. (2016). Patient experience of negative effects of psychological treatment: Results of a national survey. British Journal of Psychiatry, 208, 260-265.

Eberth, J. & Sedlmeier, P. (2012). The effects of mindfulness meditation: A meta-analysis. Mindfulness, 3, 174-189.

Garber, et al. (2011). Quantity and quality of exercise for developing and maintaining cardiorespiratory , musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise.Medicine and Science in Sports and Exercise, 43(7), 1334-1359.

Khoury, B., Lecomte, T., Fortin, G., Masse, M., Therien, P., Bouchard, V., … Hofmann, S. (2013). Mindfulness-based therapy: A comprehensive meta-analysis. Clinical Psychology Review, 33, 763-771.

Kuyken, W., Warren, F.C., Taylor, R.S., Whalley, B., Crane, C., Bondolfi, G., Hayes, R., Huijbers, M., Ma, H., Schweizer, S., Segal, Z., Speckens, A., Teasdale, J.D., Van Heeringen, K., Williams, JMG., Byford, S., Byng, R. & Dalgleish, T. (2016). Efficacy of mindfulness-based cognitive therapy in prevention of depressive relapse: An individual patient data meta-analysis from randomized trials. Journal of the American Medical Association: Psychiatry, April. Published online April 27, 2016. doi:10.1001/jamapsychiatry.2016.0076

Khoury, B., Sharma, M., Rush, S., & Fournier, C. (2015). Mindfulness-based stress reduction for healthy individuals: A meta-analysis. Journal of Psychosomatic Research, 78, 519-528.

Lilienfeld, S. O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53-70.

Malpass, A., Carel, H., Ridd, M., Shaw, A., Kessler, D., Sharp, D. … Wallond, J. (2012). Transforming the perceptual situation:  meta-ethnography of qualitative work reporting patients’ experiences of mindfulness-based approaches. Mindfulness, 3, 60-75.

Mani, M., Kavanagh, D. J., Hides, L., & Stoyanov, S. R. (2015). Review and evaluation of mindfulness-based iPhone apps. Jmir Mhealth and Uhealth, 3(3). doi: 10.2196/mhealth.4328

Rocha, T. (June 25, 2014). The dark knight of the soul: For some, meditation has become more curse than cure. Willoughby Britton wants to know why. The Atlantic.

Tang, Y., Holzel, B., & Posner, M. (2015). The neuroscience of mindfulness meditation. Nature Reviews Neuroscience, 16, 213-225.

Williams, J. M. G. & Penman, D. (2011). Mindfulness: A practical guide to finding peace in a frantic world. London: Piatkus.

Oxford Mindfulness Centre

The Oxford Mindfulness Centre (OMC) is an internationally recognised centre of excellence at the University of Oxford, and has been at the forefront of research and development in the field of mindfulness. The OMC works to advance the understanding of evidence-based mindfulness through research, publication, training and dissemination. Our world leading research investigates the mechanisms, efficacy, effectiveness, cost effectiveness and implementation of mindfulness. We offer a wide range of training, education, and clinical services, all taught by leading experts and teachers in the field, who are training the next generation of MBCT researchers, teachers and trainers. We actively engage in collaborative partnership to shape the field and influence policy nationally and internationally. Through the charitable work of the OMC, we are improving the accessibility of MBCT for those most in need. – October 2016

Please follow and like us:

Chronic Sleep Deprivation Increases Risk-Seeking Behaviour

Riskier decision-making may be a side effect of chronic sleep deprivation, a new study claims.

While chronic sleep restriction is highly prevalent, the effects and underlying mechanisms remain largely unknown for a variety of critical cognitive domains, including risky decision-making. Researchers assessed financial risk-taking behaviour in 14 healthy male students aged 28-28 years after seven continuous nights of sleep restriction and after one night of acute sleep deprivation, compared to their regular sleep condition.

It was seen that one night of sleep restriction had no impact on risk-seeking behaviour, but 11 of the 14 subjects behaved significantly and increasingly riskier as the week of reduced sleep progressed. No impact was seen following one night of acute sleep deprivation.

Despite researchers observing increased risk-seeking, this increase was not noticed subjectively.
The potential underlying mechanisms of sleep loss-induced changes to behaviour were also investigated using high-density electroencephalography recordings during restricted sleep. Locally lower values of slow wave energy during preceding sleep, an electrophysiological marker of sleep intensity and restoration, in electrodes over the right prefrontal cortex, were observed in those who engaged in the increased risk-seeking behaviour. This part of the cerebral cortex has already been associated with risk-taking behaviour in earlier studies.


Maric A, Montvai E, Werth E, Storz M, Leemann J, Weissengruber S, Ruff C, Huber R, Poryazova R, Baumann C. Insufficient sleep: Enhanced risk-seeking relates to low local sleep intensity. Ann Neurol. Published online 21 August 2017. DOI: 10.1002/ana.25023.


Please follow and like us:

25 CBT Techniques and Worksheets for Cognitive Behavioral Therapy

Sharing is caring.

25 CBT Techniques and Worksheets for Cognitive Behavioral Therapy

You have definitely heard about CBT.

You may not know it, or you may not immediately assign meaning to those three letters placed side by side, but there’s almost no doubt that you have at least a passing familiarity with CBT.

If you’ve ever interacted with a therapist, a counselor, or a clinician in a professional setting, you have likely participated in CBT. If you’ve ever heard friends or loved ones talk about how a mental health professional helped them recognize their fears or sources of distress and aided them in altering their behavior to more effectively work towards their goals, you’ve heard about the impacts of CBT.

CBT, or cognitive behavioral therapy, is one of the most used tools in the psychologist’s toolbox. It’s based on a fairly simple idea which, when put into practice, can have wildly positive outcomes.


What is CBT?

This simple idea is that our unique patterns of thinking, feeling, and behaving are significant factors in our experiences, both good and bad. Since these patterns have such a significant impact on our experiences, it follows that altering these patterns can change our experiences (Martin, 2016).

CBT aims to change our thought patterns, the beliefs we may or may not know we hold, our attitudes, and ultimately our behavior in order to help us face our difficulties and more effectively strive towards our goals.

The founder of CBT is a psychiatrist named Aaron Beck, a man who practiced psychoanalysis until he noticed the prevalence of internal dialogues in his clients, and realized how strong the link between thoughts and feelings can be. He altered the therapy he practiced in order to help his clients identify, understand, and deal with the automatic, emotion-filled thoughts that arise throughout the day.

Beck found that a combination of cognitive therapy and behavioral techniques produced the best results for his clients. In describing and honing this new therapy, Beck laid the foundations of the most popular and influential form of therapy of the last 50 years.what is cbt therapist and client working together

This form of therapy is not designed for lifelong participation, but focuses more on helping clients meet their goals in the near future. Most CBT treatment regimens last from five to ten months, with one 50 to 60 minute session per week.

CBT is a hands-on approach that requires both the therapist and the client to be invested in the process and willing to actively participate. The therapist and client work together as a team to identify the problems the client is facing, come up with new strategies for addressing them, and thinking up positive solutions (Martin, 2016).

Cognitive Distortions

Many of the most popular and effective CBT techniques are applied to what psychologists call “cognitive distortions” (Grohol, 2016).

Cognitive distortions: inaccurate thoughts that reinforce negative thought patterns or emotions.

Cognitive distortions are faulty ways of thinking that convince us of a reality that is simply not true.

There are 15 main cognitive distortions that can plague even the most balanced thinkers at times:


Filtering refers to the way many of us can somehow ignore all of the positive and good things in our day to focus solely on the negative. It can be far too easy to dwell on a single negative aspect, even when surrounded by an abundance of good things.

Polarized Thinking / “Black and White” Thinking

This cognitive distortion is all about seeing black and white only, with no shades of grey. This is all-or-nothing thinking, with no room for complexity or nuance. If you don’t perform perfectly in some area, then you may see yourself as a total failure instead of simply unskilled in one area.


Overgeneralization is taking a single incident or point in time and using it as the sole piece of evidence for a broad general conclusion. For example, a person may be on the lookout for a job but have a bad interview experience, but instead of brushing it off as one bad interview and trying again, they conclude that they are terrible at interviewing and will never get a job offer.

Jumping to Conclusions

Similar to overgeneralization, this distortion involves faulty reasoning in how we make conclusions. Instead of overgeneralizing one incident, however, jumping to conclusions refers to the tendency to be sure of something without any evidence at all. We may be convinced that someone dislikes us with only the flimsiest of proof, or we may be convinced that our fears will come true before we have a chance to find out.

Catastrophizing / Magnifying or Minimizing

This distortion involves expectations that the worst will happen or has happened, based on a slight incident that is nowhere near the tragedy that it is made out to be. For example, you may make a small mistake at work and be convinced that it will ruin the project you are working on, your boss will be furious, and you will lose your job. Alternatively, we may minimize the importance of positive things, such as an accomplishment at work or a desirable personal characteristic.


This is a distortion where an individual believes that everything they do has an impact on external events or other people, no matter how irrational the link between. The person suffering from this distortion will feel that they have an unreasonably important role in the bad things that happen around them. For instance, a person may believe that the meeting they were a few minutes late in getting to was derailed because of them, and that everything would have been fine if they were on time.

Control Fallacies

Another distortion involves feeling that everything that happens to you is a result of external forces or due to your own actions. Sometimes what happens to us is due to forces we can’t control, and sometimes what happens is due to our actions, but the false thinking is in assuming that it is always one or the other. We may assume that the quality of our work is due to working with difficult people, or alternatively that every mistake someone else makes is due to something we did.

Cognitive Distortions

Fallacy of Fairness

We are often concerned about fairness, but this concern can be taken to extremes. As we know, life is not always fair. The person who goes through life looking for fairness in all their experiences will end up resentful and unhappy. Sometimes things will go our way, and sometimes they will not, regardless of how fair it may seem.


When things don’t go our way, there are many ways we can explain or assign responsibility for the outcome. One method of assigning responsibility is blaming others for what goes wrong. Sometimes we may blame others for making us feel or act a certain way, but this is a cognitive distortion because we are the only ones responsible for the way we feel or act.


“Shoulds” refer to the implicit or explicit rules we have about how we and others should behave. When others break our rules, we are upset. When we break our own rules, we feel guilty. For example, we may have an unofficial rule that customer service representatives should always be accommodating to the customer. When we interact with a customer service representative that is not immediately accommodating, we might get angry. If we have an implicit rule that we are irresponsible if we spend money on unnecessary things, we may feel exceedingly guilty when we spend even a small amount of money on something we don’t need.

Emotional Reasoning

This distortion involves thinking that if we feel a certain way, it must be true. For example, if we feel unattractive or uninteresting in the current moment, we must be unattractive or uninteresting. This cognitive distortion boils down to:

“I feel it, therefore it must be true.”

Clearly our emotions are not always indicative of the objective truth, but it can be difficult to look past how we feel.

Fallacy of Change

The fallacy of change lies in expecting other people to change as it suits us. This ties into the feeling that our happiness depends on other people, and their unwillingness or inability to change, even if we push and press and demand it, keeps us from being happy. This is clearly a damaging way to think, since no one is responsible for our happiness except for us.

Global Labeling / Mislabeling

This cognitive distortion is an extreme form of generalizing, in which we generalize one or two instances or qualities into a global judgment. For example, if we fail at a specific task, we may conclude that we are a total failure in not only this area, but all areas. Alternatively, when a stranger says something a bit rude, we may conclude that he or she is an unfriendly person in general. Mislabeling is specific to using exaggerated and emotionally loaded language, such as saying a woman has abandoned her children when she leaves her children with a babysitter to enjoy a night out.

Always Being Right

While we all enjoy being right, this distortion makes us think we must be right, that being wrong is unacceptable. We may believe that being right is more important than the feelings of others, being able to admit when we’ve made a mistake, or being fair and objective.

Heaven’s Reward Fallacy

This distortion involves expecting that any sacrifice or self-denial on our part will pay off. We may consider this karma, and expect that karma will always immediately reward us for our good deeds. Of course, this results in feelings of bitterness when we do not receive our reward (Grohol, 2016).

Many tools and techniques found in CBT are intended to address or reverse these cognitive distortions.

9 Essential CBT Techniques and Tools

There are many tools and techniques used in CBT, many of which have spread from the therapy context to everyday life. The nine techniques and tools listed below are some of the most common and effective CBT practices.


This technique is a way of “gathering data” about our moods and our thoughts. This journal can include the time of the mood or thought, the source of it, the extent or intensity, and how we responded to it, among other factors. ThisEssential CBT Techniques and Tools technique can help us to identify our thought patterns and emotional tendencies, describe them, and find out how to change, adapt, or cope with them.

Unraveling Cognitive Distortions

This is a main goal of CBT, and can be practiced with or without the help of a therapist. In order to unravel the cognitive distortions you hold, you must first become aware of which distortions you are most vulnerable to. Part of this involves identifying and challenging our harmful automatic thoughts, which frequently fall into one of the categories listed earlier.

Cognitive Restructuring

Once you identify the distortions or inaccurate views on the world you hold, you can begin to learn about how this distortion took root and why you came to believe it. When you discover a belief that is destructive or harmful, you can begin to challenge it. For example, if you believe that you must have a high paying job to be a respectable person, but you lose your high paying job, you will begin to feel bad about yourself.

Instead of accepting this faulty belief that leads you to think unreasonably negative thoughts about yourself, you could take this opportunity to think about what makes a person “respectable,” a belief you may not have explicitly considered before.

Exposure and Response Prevention

This technique is specifically effective for those who suffer from obsessive compulsive disorder (OCD). You can practice this technique by exposing yourself to whatever it is that normally elicits a compulsive behavior, but doing your best to refrain from the behavior and writing about it. You can combine journaling with this technique, or use journaling to understand how this technique makes you feel.

Interoceptive Exposure

This technique is intended to treat panic and anxiety. It involves exposure to feared bodily sensations in order to elicit the response, activate any unhelpful beliefs associated with the sensations, maintain the sensations without distraction or avoidance, and allow new learning about the sensations to take place. It is intended to help the sufferer see that symptoms of panic are not dangerous, although they may be uncomfortable.

Nightmare Exposure and Rescripting

Nightmare exposure and rescripting is intended specifically for those suffering from nightmares. This technique is similar to interoceptive exposure, in that the nightmare is elicited, which brings up the relevant emotion. Once the emotion has arisen, the client and therapist work together to identify the desired emotion and develop a new image to accompany the desired emotion.

Play the Script Until the End

This technique is especially useful for those suffering from fear and anxiety. In this technique, the individual who is vulnerable to crippling fear or anxiety conducts a sort of thought experiment, where they imagine the outcome of the worst case scenario. Letting this scenario play out can help the individual to recognize that even if everything they fear comes to pass, it will likely turn out okay.

Progressive Muscle Relaxation (PMR)

This is a familiar technique to those who practice mindfulness. Similar to the body scan, this technique instructs you to relax one muscle group at a time until your whole body is in a state of Essential CBT Techniques and Toolsrelaxation. You can use audio guidance, a YouTube video, or simply your own mind to practice this technique, and it can be especially helpful for calming nerves and soothing a buy and unfocused mind.

Relaxed Breathing

This is another technique that is not specific to CBT, but will be familiar to practitioners of mindfulness. There are many ways to relax and bring regularity to your breath, including guided and unguided imagery, audio recordings, YouTube videos, and scripts. Bringing regularity and calm to your breath will allow you to approach your problems from a place of balance, facilitating more effective and rational decision making (Megan, 2016).

These techniques can help those suffering from a range of mental illnesses and afflictions, including anxiety, depression, OCD, and panic disorder, and they can be practiced with or without the guidance of a therapist. To try some of these techniques without the help of a therapist, see the next section for worksheets and handouts to assist with your practice.

Cognitive Behavioral Therapy Worksheets (PDF) To Print and Use

If you’re a therapist looking for ways to guide your client through treatment or a hands-on person who loves to learn by doing, there are many CBT worksheets that can help.

Alternative Action Formulation

This worksheet instructs the user to first list any problems or difficulties you are having. Next, you list your vulnerabilities (i.e., why you are more likely to experience these problems than someone else) and triggers (i.e., the stimulus or source of these problems).

Once you have defined the problems and understand why you are struggling with them, you go on to list coping strategies. These are not solutions to problems, but ways in which you can deal with the effects of these problems that can have a temporary impact. Next, you list the effects of these coping strategies, such as how they make you feel in the short-term and long-term, and the advantages and disadvantages of each strategy.

Finally, you move on to listing alternative actions. If your coping strategies are not totally effective against the problems and difficulties that are happening, you are instructed to list other strategies that may work better.

This worksheet gets you (or your client) thinking about what you are doing now and whether it is the best way forward. You can find it here.

Cognitive Behavioral Therapy Worksheets (PDF) To Print and Use

Functional Analysis

One popular technique in CBT is functional analysis. This technique helps you (or the client) learn about yourself, specifically what leads to specific behaviors and what consequences result from those behaviors.

In the middle of the worksheet is a box labeled “Behaviors.” In this box, you write down any potentially problematic behaviors or other behaviors you wish to analyze.

On the left side of the worksheet is a box labeled “Antecedents,” in which you or the client write down the factors that preceded a particular behavior. These are factors that led up to the behavior under consideration, either directly or indirectly.

On the right side is the final box, labeled “Consequences.” This is where you write down the consequences of the behavior, or what happened as a result of the behavior under consideration. “Consequences” may sound inherently negative, but they are not necessarily negative; some positive consequences can arise from many types of behaviors, even if more negative consequences result as well.

This worksheet can help you or your client to find out whether particular behaviors are adaptive and helpful in striving towards your goals, or destructive and self-defeating. Follow this link to print out this worksheet and give it a try.

Longitudinal Formulation

This worksheet helps you address what some CBT therapists call the “5 P Factors” – presenting, predisposing, precipitating, perpetuating, and positives. This formulation process can help you connect the dots between your core beliefs and thought patterns and your present behavior.

This worksheet presents five boxes at the top of the page, which should be completed before moving on to the rest of the worksheet.

  1. The first box is labeled “Precipitating Events / Triggers,” and corresponds with the Precipitating factor. In this box, you are instructed to write down the events or stimuli that provoke a certain behavior.
  2. The next box is labeled “Early Experiences” and corresponds to the Predisposing factor. This is where you list the experiences that you had early on, all the way back to childhood, that may have contributed to the behavior.
  3. The third box is “Core Beliefs,” which is also related to the Predisposing factor. This is where you write down some of the relevant core beliefs you have regarding this behavior. These are beliefs that may not be explicit, but that you believe deep down, such as “I’m bad” or “I’m not good enough.”
  4. The fourth box is “Old Rules for Living,” which is where you list the rules that you adhere to, whether consciously or subconsciously. These implicit or explicit rules can perpetuate the behavior, even if it is not helpful or adaptive. Rules are if-then statements that provide a judgment based on a set of circumstances. For instance, you may have the rule “If I do not do something perfectly, I’m a complete failure.”
  5. The final box is labeled “Presenting Problems / Effects of Old Rules.” This is where you write down how well these rules are working for you. Are they helping you to be the best you can be? Are they helping you to effectively strive towards your goals?


Below this box there are two flow charts that you can fill out based on how these behaviors and feelingsare perpetuated. You are instructed to think of a situation that produces a negative automatic thought, and record the emotion and the behavior that this thought provokes, as well as the bodily sensations that can result. Filling out these flow charts can help you see what drives your behavior or thought and what results from it.

Below these two charts is the box “Protective Factors.” This is where you list the factors that can help you deal with the problematic behavior or thought, and perhaps help you break the perpetuating cycle. This can be things that help you cope once the thought or behavior arises or things that can disrupt the pattern once it is in motion.

Finally, the last box is “New Rules for Living.” This box relates to the Positive factor, in that it provides you with an opportunity to create new rules for yourself that will disrupt the destructive cycle and allow you to become more effective in meeting your therapeutic goals. Click here if you’d like to try this worksheet.

Dysfunctional Thought Record

This worksheet is especially helpful for people who are struggling with negative thoughts and need to figure out when and why they are most likely to pop up. By learning more about what provokes certain automatic thoughts, they become easier to address and reverse.

The worksheet is divided into seven columns:

  1. On the far left, there is space to write down the date and time a dysfunctional thought arose.
  2. The second column is where the situation is listed. The user is instructed to describe the event that led up to the dysfunctional thought in detail.
  3. The third column is for the automatic thought. This is where the dysfunctional automatic thought is recorded, along with a rating of belief in the thought on a scale from 0% to 100%.
  4. The next column is where the emotion or emotions elicited by this thought are listed, also with a rating of intensity on a scale from 0% to 100%.
  5. The fifth column is labeled “Distortion.” This column is where the user will identify which cognitive distortion(s) they are suffering from with regards to this specific dysfunctional thought, such as all-or-nothing thinking, filtering, jumping to conclusions, etc.
  6. The second to last column is for the user to write down alternative thoughts, more positive and functional thoughts that can replace the negative one.
  7. Finally, the last column is for the user to write down the outcome of this exercise. Were you able to confront the dysfunctional thought? Did you write down a convincing alternative thought? Did your belief in the thought and/or the intensity of your emotion(s) decrease? To give this worksheet a try, click here.

Fact or OpinionCognitive Behavioral Therapy Worksheets (PDF) To Print and Use

One of my favorite CBT worksheets is the “Fact or Opinion” worksheet, because it can be extremely helpful in recognizing that your thoughts are not necessarily true.

At the top of this worksheet is an important lesson:

Thoughts are not facts.

Of course, it can be hard to accept this, especially when we are in the throes of a dysfunctional thought or intense emotion. Filling out this worksheet can help you come to this realization.

The worksheet includes 16 statements that the user must decide are either fact or opinion. These statements include:

  • I’m a bad person.
  • I failed the test.
  • I’m selfish.
  • I didn’t lend my friend money when they asked.


This is not a trick – there is a right answer for each of these statements. (In case you’re wondering, the right answers for the statements above are as follows: opinion, fact, opinion, fact.)

This simple exercise can help the user to see that while we have lots of emotionally charged thoughts, they are not all objective truths. Recognizing the difference between fact and opinion can assist us in challenging the dysfunctional or harmful opinions we have about ourselves and others.

If you’d like to print out this worksheet to give it a try, click here.

Cognitive Restructuring

This worksheet employs the use of Socratic questioning, a technique that can help the user to challenge irrational or illogical thoughts.

The top of the worksheet describes how thoughts are a running dialogue in our minds, and they can come and go so fast that we hardly have time to address them. This worksheet aims to help us capture one or two of these thoughts and analyze them.

  1. The first box to be filled out is “Thoughts to be questioned.” This is where you write down a specific thought, usually one you suspect is destructive or irrational.
  2. Next, you write down the evidence for and against this thought. What evidence is there that this thought is accurate? What evidence exists that calls it into question?
  3. Once you have identified the evidence, you can make a judgment on this thought, specifically whether it is based on facts or your feelings.
  4. Next, you answer a question on whether this thought is truly a black and white situation, or whether reality leaves room for shades of grey. This is where you think about whether you are using all-or-nothing thinking, or making things unreasonably simple when they are truly complex.
  5. In the last box on this page, you consider whether you could be misinterpreting the evidence or making any unverified assumptions.


On the next page, you are instructed to think about whether other people might have different interpretations of the same situation, and what those interpretations might be.

Next, ask yourself whether you are looking at all the relevant evidence, or just the evidence that backs up the belief you already hold. Try to be as objective as possible.

The next box asks you whether your thought may an exaggeration of a truth. Some negative thoughts are based in truth, but extended past their logical boundaries.

Next, you are instructed to consider whether you are entertaining this negative thought out of habit or because the facts truly support it.

Once you have decided whether the facts support this thought, you are encouraged to think about how this thought came to you. Was it passed on from someone else? If so, are they a reliable source for truth?

Finally, you complete the worksheet by identifying how likely the scenario your thought brings up actually is, and whether it is the worst case scenario.

These “Socratic questions” encourage a deep dive into the thoughts that may plague you, and offer an opportunity to analyze and evaluate them for truth. If you are having thoughts that do not come from a place of truth, this worksheet can be an excellent tool for identifying and defusing them.

For more CBT worksheets and handouts, visit this website.

Some More CBT Interventions and Exercises

Haven’t had enough CBT tools and techniques yet? Continue on for more useful and effective exercises!

Behavioral Experiments

These are related to thought experiments, in that you engage in a “what if” consideration. Behavioral experiments differ from thought experiments in that you actually test out these “what ifs” outside of your thoughts (Boyes, 2012).

In order to test a thought, you can experiment with the outcomes that different thoughts produce. For example, you can test the thought:

“If I criticize myself, I will be motivated to work harder” vs. “If I am kind to myself, I will be motivated to work harder.”

First, you would try criticizing yourself when you need motivation to work harder and record the results. Then you would try being kind to yourself and recording the results. Next, you would compare the results to see which thought was closer to the Behavioral Experiments CBT Interventions and Exercisestruth.

These behavioral experiments can help you learn how to best strive towards your therapeutic goals and how to be your best self.

Thought Records

Thought records are useful in testing the validity of your thoughts (Boyes, 2012). They involve gathering and evaluating the evidence for and against a particular thought, allowing for an evidence-based conclusion on whether the thought is valid or not.

For example, you may have the belief “My friend thinks I’m a bad friend.” You would think of all the evidence for this belief, such as “She didn’t answer the phone the last time I called” or “She cancelled our plans at the last minute”, and evidence against this belief, like “She called me back after not answering the phone” and “She invited me to her barbecue next week. If she thought I was a bad friend, she probably wouldn’t have invited me.”

Once you have evidence for and against, the goal is to come up with more balanced thoughts, such as

“My friend is busy and has other friends, so she can’t always answer the phone when I call. If I am understanding of this, I will truly be a good friend.”

Thought records apply the use of logic to ward off unreasonable negative thoughts and replace them with more balanced, rational thoughts (Boyes, 2012).

Pleasant Activity Scheduling

This technique can be especially helpful for dealing with depression (Boyes, 2012). It involves scheduling activities in the near future that you can look forward to.

For example, you may write down one activity per day that you will engage in over the next week. This can be as simple as watching a movie you are excited to see or calling a friend to chat. It can be anything that is pleasant to you, as long as it is not unhealthy (i.e., eating a whole cake in one sitting or smoking).

You can also try scheduling an activity for each day that provides you with a sense of mastery or accomplishment (Boyes, 2012). It’s great to do something pleasant, but doing something small that can make you feel accomplished may have longer lasting and farther reaching effects.

This simple technique can introduce more positivity into your day and help you make your thinking less negative.

Imagery Based Exposure

This exercise involves thinking about a recent memory that produced strong negative emotions and analyzing the situation.

For example, if you recently had a fight with your significant other and they said something hurtful, you can bring that situation to mind and try to remember it in detail. Next, you would try to label the emotions and thoughts you experienced during the situation and identify the urges you felt (e.g., to run away, to yell at your significant other, to cry).

Visualizing this negative situation, especially for a prolonged period of time, can help you to take away its ability to trigger you and reduce avoidance coping (Boyes, 2012). When you expose yourself to all of the feelings and urges you felt in the situation and survive experiencing the memory, it takes some of its power away.

Situation Exposure Hierarchies

This technique may sound complicated, but it’s relatively simple.

Situation Exposure Hierarchies involves making a list of things that you would normally avoid (Boyes, 2012). For example, someone with severe social anxiety may typically avoid making a phone call instead of emailing or asking someone on a date.

Next, you rate each item on how distressed you think you would be, on a scale from 0 to 10, if you engaged in it. For the person suffering from severe social anxiety, asking someone on a date may be rated a 10 on the scale, while making a phone call instead of emailing might be rated closer to a 3 or 4.

Once you have rated each item, you rank them according to their distress rating. This will help you recognize the biggest difficulties you face, which can help you decide which items to address and in what order. It may be best to start with the less distressing items and work your way up to the most distressing items.

Situation Exposure Hierarchies CBT Interventions and Exercises

A CBT Manual and Workbook for Your Own Practice + for Your Client

If you’re interested in giving CBT a try with your clients, there are many books and manuals that can help get you started. Some of these books are for the therapist only, and some are to be navigated as a team or with guidance from the therapist.

There are many manuals out there for helping therapists apply CBT in their work, but these are some of the most popular:


For clients or for therapist and client to work through together, these are some of the most popular manuals and workbooks:

There are many other manuals and workbooks out there that can help get you started with CBT, but these are a good start.

5 Last Cognitive Behavioral Activities

Before we go, there are a few more CBT activities and exercises that may be helpful for you or your clients that we’d like to cover.

Mindfulness Meditation

As readers of this blog will likely know by now, mindfulness can have a wide range of positive impacts, including helping with depression, anxiety, addiction, and many other mental illnesses or difficulties.

Mindfulness can help those suffering from harmful automatic Cognitive Behavioral Activitiesthoughts to disengage from rumination and obsession over these thoughts by helping them stay firmly grounded in the present.

Successive Approximation

This is a somewhat fancy name for a simple idea that you have likely already hear of: breaking up large tasks into small steps to make it easier to accomplish.

It can be overwhelming to be faced with a huge goal we would like to accomplish, like opening a business or remodeling a house. This is true in mental health treatment as well, since the goal to overcome depression or anxiety and achieve mental wellness can seem like a monumental task to those who are suffering from severe symptoms.

By breaking the large goal into small, easy to accomplish steps, we can map out the path to success and make the journey seem a little less overwhelming.

Writing Self-Statements to Counteract Negative Thoughts

This technique can be difficult for someone just beginning their CBT treatment or suffering from severe symptoms, but it can also be extremely effective (Anderson, 2014).

When you (or your client) are being plagued by negative thoughts, it can be hard to confront them, especially if your belief in these thoughts is strong. To counteract these negative thoughts, it can be helpful to write down a positive, opposite thought.

For example, if the thought that you are worthless keeps popping into your head, try writing down a statement like “I am a person with worth” or “I am person with potential.” In the beginning, it can be difficult to accept these replacement thoughts, but the more you bring out these positive thoughts to counteract the negative ones, the stronger the association will be.

Visualize the Best Parts of Your Day

When you are feeling depressed or negative, it is difficult to recognize that there is good in your life as well. This simple technique of bringing to mind the good parts of your day can be a small step in the direction of recognizing the positive (Anderson, 2014).

All you need to do is write down the things in your life that you are most thankful for or the things that are most positive in your day. The simple act of writing down these good things can forge new associations in your mind which make it easier to see the positive, even when there is plenty of negative as well.

Reframe Your Negative Thoughts

It can be all too easy to succumb to negative thoughts as a default setting. If you find yourself immediately thinking a negative thought when you see something new, such as entering an unfamiliar room and thinking “I hate the color of that wall,” give reframing a try (Anderson, 2014).

Reframing involves countering the negative thought(s) by noticing things you feel positive about as quickly as possible. For instance, in the example where you immediately think of how much you hate the color of that wall, you would push yourself to notice five things in the room that you feel positively about (e.g., the carpet looks comfortable, the lampshade is pretty, the windows let in a lot of sunshine).

You can set your phone to remind you throughout the day to stop what you are doing and think of the positive things around you. This can help you to push your thoughts back into the realm of the positive instead of the negative.

Cognitive Behavioral Activities

A Take Home Message

As always, I hope this post has been helpful. There are a lot of great tips and techniques in here that can be extremely effective in the battle against depression, anxiety, OCD, and a host of other problems or difficulties.

However, as is the case with many treatments, they depend on you (or your client) putting in a lot of effort. I would encourage you to give these techniques a real try, and allow yourself the luxury of thinking they may actually work. When we approach a potential solution with the assumption that it will not work, then it will probably not work. When we approach a potential solution with an open mind and the thought that it just might work, it has a much better chance of succeeding.

So if you are struggling with negative automatic thoughts, please consider these tips and techniques and give them a real shot. Likewise, if your client is struggling, encourage them to make the effort, because the payoff can be better than they can imagine.

If you are struggling with severe symptoms of depression or suicidal thoughts, please call the following number in your respective country:

  • USA: National Suicide Prevention Hotline at 1-800-273-8255
  • UK: Samaritans hotline at 116 123
  • The Netherlands: Netherlands Suicide Hotline at 09000767
  • France: Suicide écoute at 01 45 39 40 00
  • Germany: Telefonseelsorge at 0800 111 0 111 for Protestants, 0800 111 0 222 for Catholics, and 0800 111 0 333 for children and youth

For a list of other suicide prevention websites, phone numbers, and resources, see this website.

Please know that there are people out there who care and that there are treatments that can help.

Thank you for reading, and please let us know about your experiences with CBT in the comments section. Have you tried it? How did it work for you? Are there any other helpful exercises or techniques that we did not touch on in this piece?


Please follow and like us: