Adapting Cognitive Behavioral Therapy to Each Client

Sometimes I hear that cognitive behavioral therapy is formulaic. It can also seem overly standardized, routine, or one-size-fits-none. Cognitive behavioral therapy is actually a very adaptable treatment with multiple opportunities for tailoring to each client.

However, I would like to acknowledge where this myth likely comes from. Cognitive behavioral therapy is very well-studied in clinical trials. Treatments in clinical trials have to be regimented almost to the point of scripting what is said to each client. This can often seem formulaic. Another potential source is the cognitive behavioral therapist’s love of treatment manuals. Treatment manuals are guidebooks that dictate how, when and which therapeutic techniques are used. There are also a lot of worksheets. Overreliance on the treatment manuals, which are supposed to be tailored by the therapist to each client, can sometimes seem like a one-size-fits-all approach.

Okay, so with the caveat that cognitive behavioral therapy might seem standardized in specific instances, let’s get into how it can be adapted to each client. First, cognitive therapy focuses on challenging negative automatic thoughts about an event or stressful situation. The content of these thoughts always has to come from the client and is therefore tailored to the client. A therapist might give suggestions of common automatic thoughts if a client is having trouble identifying the thought but ultimately, it’s whatever the client is thinking.

Cognitive behavioral therapy also adapts the techniques for challenging negative automatic thoughts. The most common technique is examining the evidence for and against the thought then generating a more balanced thought that accounts for all the evidence. Another common technique is identifying specific cognitive distortions. Cognitive distortions are errors in how we think about the world and ourselves. These have memorable names like all-or-nothing thinking or minimizing or magnifying. Other techniques for challenging negative automatic thoughts involve asking a question such as "what would you tell a friend" or "what would someone else looking in say."

My personal favorite is conducting an experiment to see if the thought is true. For example, if I have the thought "I’ll never do that yoga pose," I can test that thought by training to do that yoga pose. Sometimes we use worksheets for this process, sometimes we don’t. Sometimes we use very elaborate complicated worksheets, sometimes simple worksheets with four spaces: the event, the automatic thought, the emotion, and the more realistic thought. In addition to the negative thoughts themselves, cognitive behavioral therapy adapts the specific technique for challenging those thoughts.

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One way cognitive behavioral therapy is tailored in practice is the amount of time spent on specific techniques. This differs from clinical trials where the content of each session may be dictated by the trial. In practice, cognitive behavioral therapy will shift focus depending on the client’s needs. Some clients may need to spend more time learning to identify negative automatic thoughts. Others may need to spend more time testing out different techniques for challenging those thoughts, to see what works best for them. Sometimes therapy focuses more on negative automatic thoughts, and other times therapy focuses on core beliefs that drive automatic thoughts. For some clients, the behavioral aspect of treatment might work better and little time is spent on challenging automatic thoughts.

Cognitive behavioral therapy is better understood as a philosophy of treatment that focuses on thoughts and behavior. While it can sometimes seem formulaic, cognitive behavioral therapy can easily be adapted to what works best for different clients. Just know that a worksheet may be offered at some point.