Cognitive Behavior Therapy

Describe the key concepts and phases of Meichenbaum's stress inoculation training.

A particular application of a coping skills program is teaching clients stress management techniques by way of a strategy known as stress inoculation training (SIT). Using cognitive techniques, Meichenbaum (1985, 2007, 2008) has developed stress inoculation procedures that are a psychological and behavioral analog to immunization on a biological level. Individuals are given opportunities to deal with relatively mild stress stimuli in successful ways, and they gradually develop a toler- ance for stronger stimuli. This training is based on the assumption that we can affect our ability to cope with stress by modifying our beliefs and self-statements about our performance in stressful situations.training is concerned with more than merely teaching people specific coping skills. His program is designed to prepare clients for intervention and motivate them to change, and it deals with issues such as resistance and relapse. Stress inoculation training is a combination of information giving, Socratic discovery-oriented inquiry, cognitive restructuring, problem solving, relaxation training, behavioral rehearsals, self-monitoring, self-instruction, self-reinforcement, and modifying environmental situations (Meichenbaum, 2008). Collaborative goals are set that nurture hope, direct-action skills, and acceptance-based coping skills. These coping skills are designed to be applied to both present problems and future difficulties. Clients are assisted in generalizing what they have learned so they can use these skills in daily living, and relapse prevention strategies are taught. Meichen- baum (2008) describes stress inoculation training as a complex, multifaceted, cogni- tive behavioral intervention that is both a preventive and a treatment approach. Meichenbaum (2007, 2008) has designed a three-stage model for stress inoculation training: (1) the conceptual-educational phase, the primary focus is on creating a ther- apeutic alliance with clients. This is done by helping clients gain a better under- standing of the nature of stress and reconceptualizing it in social-interactive terms. Initially, clients are provided with a conceptual framework in simple terms designed to educate them about ways of responding to a variety of stressful situations. (2) the skills acquisition and consolidation phase, the focus is on giving clients a variety of behavioral and cognitive coping skills to apply to stressful situations. This phase involves direct actions, such as gathering information about their fears, learning specifically what situations bring about stress, arranging for ways to lessen the stress by doing something different, and learning methods of physical and psychological relaxation. The training involves cognitive coping; clients are taught that adaptive and maladaptive behaviors are linked to their inner dialogue. (3) the application and follow-through phase. the focus is on carefully arranging for transfer and maintenance of change from the therapeutic situation to everyday life. Clients practice their new self-statements and apply their new skills to everyday life. To consolidate the lessons learned in the training sessions, clients participate in a variety of activities, including imagery and behavior rehearsal, role playing, model- ing, and graded in-vivo exposure. Once clients have become proficient in cognitive and behavioral coping skills, they practice behavioral assignments, which become increasingly demanding. relapse prevention, which consists of procedures for dealing with the inevi- table setbacks clients are likely to experience as they apply what they are learning to daily life, is taught at this stage (Marlatt & Donovan, 2005). Clients learn to view any lapses that occur as "learning opportunities" rather than as "catastrophic failures." Clients explore a variety of possible high-risk, stressful situations that they may reex- perience.

Identify common attributes shared by all cognitive behavior approaches.

All of the cognitive behavioral approaches share the same basic characteristics and assumptions as traditional behavior therapy. Although the approaches are quite diverse, they do share these attributes: (1) a collaborative rela- tionship between client and therapist, (2) the premise that psychological distress is often maintained by cognitive processes, (3) a focus on changing cognitions to produce desired changes in affect and behavior, (4) a present-centered, time-limited focus, (5) an active and directive stance by the therapist, and (6) an educational treatment focusing on specific and structured target problems In addition, both cognitive therapy and the cognitive behavioral therapies are based on a structured psychoeducational model, make use of homework, place responsibility on the client to assume an active role both during and outside ther- apy sessions, emphasize developing a strong therapeutic alliance, and draw from a variety of cognitive and behavioral strategies to bring about change. Therapists help clients examine how they understand themselves and their world and suggest ways clients can experiment with new ways of behaving To a large degree, both cognitive therapy and cognitive behavior therapy are based on the assumption that beliefs, behaviors, emotions, and physical reactions are all reciprocally linked. CBT therapists apply behavioral techniques such as operant condi- tioning, modeling, and behavioral rehearsal to the more subjective processes of think- ing and internal dialogue. In addition, therapists help clients actively test their beliefs in therapy, on paper, and through behavioral experiments. Cognitive therapy and the cognitive behavioral approaches include a variety of behavioral strategies

Understand the unique contributions of Aaron Beck to the development of cognitive therapy. What is generic cognitive model?

CT emphasizes education and prevention but uses specific methods tai- lored to particular issues. The specificity of CT allows therapists to link assessment, conceptualization, and treatment strategies. CT approaches were developed for many disorders including depression, panic disorder, social anxiety, phobias, posttraumatic stress disorder, schizophrenia and other psychotic disorders, hypochondriasis, body dysmorphic disorder, eating disorders, insomnia, anger issues, stress, chronic pain and fatigue, and distress due to general medical problems such as cancer Beck's original depression research revealed that depressed clients had a nega- tive bias in their interpretation of certain life events, which resulted from active pro- cesses of cognitive distortion (A. Beck, 1967). This led Beck to believe that a therapy that helped depressed clients become aware of and change their negative thinking could be helpful. Beck's research indicated that depression could result from negative thinking, but it could also be precipitated by genetic, neurobiological, or environmental changes. One of Beck's early contributions was to recognize that regardless of the cause of depression, once people became depressed, their thinking reflected what Beck referred to as the negative cognitive triad: negative views of the self (self-criticism),the world (pessimism), and the future (hopelessness). Beck believed this negative cognitive triad maintained depression, even when negative thoughts were not the original cause of an episode of depression CT is based on the theoretical rationale that the way people feel and behave is influenced by how they perceive and place meaning on their experience. Three theoretical assumptions of CT are (1) that people's thought processes are accessible to introspection, (2) that people's beliefs have highly personal meanings, and (3) that people can discover these meanings themselves rather than being taught or having them interpreted by the therapist generic cognitive model to describe principles that pertain to all CT applications from depression and anxiety treatments to therapies for a wide variety of other problems including psychosis and substance use By linking psychological difficulties with adaptive human responses, Beck believes the generic cognitive model "has the potential to be the only empiri- cally supported general theory of psychopathology" (A. Beck & Haigh, 2014, p. 21). The generic cognitive model provides a comprehensive framework for understand- ing psychological distress, and some of its major principles are described here. Beck encouraged others to design research to investigate the components of his model in an effort to reach the best understanding possible of human cognition, behavior, and emotion. L

Know some of the main differences in how Ellis, Beck, Padesky, and Meichenbaum apply CBT in practice.

Ellis's REBT I question the REBT assumption that exploring the past is ineffective in helping clients change faulty thinking and behavior. From my perspective, exploring past childhood experiences can have a great deal of therapeutic power if the discussion is connected to present functioning. In fact, Albert Ellis would (and Debbie Joffe Ellis continues to) listen to past childhood experiences in the initial session, or during early sessions. These stories can be valuable as sources of irrational beliefs still held by the client in the here and now. Attention would then very quickly move to exploring, disputing, and replacing these beliefs.Another potential limitation involves the misuse of the therapist's power by imposing ideas of what constitutes rational thinking. Due to the active and direc- tive nature of this approach, it is particularly important for practitioners to avoid imposing their own philosophy of life on their clients. The skillful REBT therapist clarifies the REBT definitions of rational versus irrational thoughts and healthy neg- ative emotions versus unhealthy negative emotions (A. Ellis & Ellis, 2011). Some clients may have trouble with a confrontational style of REBT, especially if a strong therapeutic alliance has not been established. It is well to underscore that REBT can be effective when practiced in a style different from Ellis's. Albert Ellis often expressed that therapists do not need to emulate his style to effectively incorporate REBT into their own repertoire of interventions. Debbie Joffe Ellis, who continues to teach and write about the "Ellis" REBT approach, enthusiastically encourages therapists to adhere to REBT tenets and principles in their own authen- tic manner and style (D. Ellis, 2014). Beck's Cognitive Therapy Cognitive therapy has been criticized for focusing too much on the power of positive thinking; being too superficial and simplistic; denying the importance of the client's past; being too technique oriented; failing touse the therapeutic relationship; working only on eliminating symptoms, but failing to explore the underlying causes of difficulties; ignoring the role of unconscious factors; and neglecting the role of feelings (Freeman & Dattilio, 1992; Weisha Padesky and Mooney's Strengths-Based CBT The biggest criticism of strengths- based CBT is that the evidence base supporting the approach is still in its infancy. Some CBT therapists question whether the addition of client strengths adds anything to CBT's effectiveness. Studies currently under way in Europe and the United Kingdom are testing this hypothesis, especially to see whether a strengths and resilience focus increases the enduring effects of therapy. Further research is necessary to examine whether construction of new beliefs and behaviors is more effective than examining current beliefs and behaviors in the treatment of chronic problems. Meichenbaum's Cognitive Behavior Modification Meichenbaum is very charismatic in his workshop presentations. Much of the success of his approach may be based on his level of caring and his creativity in implementing CBT interventions. Practitioners without his wit, energy, personal flair, and direct therapeutic style may not get the same results even though they follow his treatment protocol. This emphasizes the importance for each therapist to develop his or her own unique therapeutic style. All A potential limitation of any of the cognitive behavioral approaches is the thera- pist's level of personal development, training, knowledge, skill, perceptiveness, and ability to establish a therapeutic alliance. Although this is true of all therapeutic approaches, it is especially true for CBT practitioners because they tend to be active, highly structured, offer clients useful information, and teach life skills. Who the ther- apist is as a person is as important as knowledge and skills. Therapists teach their clients through what they model. Debbie Joffe Ellis (2014) encourages practitioners to strive to be mindful, to think about their thinking, and to do their best to practice what they preach. In so doing, they can be healthy models for their clients and others and experience greater authenticity and satisfaction in their own lives as well.

Identify the strengths and limitations of cognitive behavior therapy from a multicultural perspective.

If therapists under- stand the core values of their culturally diverse clients, they can help clients explore these values and gain a full awareness of their conflicting feelings. Then the client and the therapist can work together to modify selected beliefs and practices. Cogni- tive behavior therapy tends to be culturally sensitive because it uses the individual's belief system, or worldview, as part of the method of self-exploration. A strength of CBT is integrating assessment of client beliefs, emotional responses, and behavioral choices throughout therapy, which communicates respect for clients' viewpoints regarding their progress. Because counselors with a cognitive behavioral orientation function as teach- ers, clients are actively involved in learning skills to deal with the problems of living. In speaking with colleagues who work with culturally diverse populations, I have learned that their clients tend to appreciate the emphasis on cognition and action, as well as the stress on relationship issues. The collaborative approach of CBT offers clients a structured therapy program, yet the therapist still makes every effort to enlist clients' active cooperation and participation. shortcomings The emphasis of CBT on assertiveness, independence, verbal ability, ratio- nality, cognition, and behavioral change may limit its use in cultures that value subtle communication over assertiveness, interdependence over personal inde- pendence, listening and observing over talking, and acceptance over behavior change (Hays, 2009). In CBT the focus is on the present, which can result in the therapist failing to recognize the role of the past in a client's development. Cognitive behavioral assessments involve the investigation of a client's personal history. If the therapist is unaware of a client's cultural beliefs, which are rooted in the past, the therapist may have difficulty interpreting the client's personal experiences accurately. Another limitation of CBT from a multicultural perspective involves its indi- vidualistic orientation. An inexperienced therapist may overemphasize cognitive restructuring to the neglect of environmental interventions. Hays (2009) points out that these potential limitations do not preclude the integration of CBT and multi- cultural counseling. Instead, being aware of these limitations "presents opportuni- ties for rethinking, refining, adapting and increasing the relevance and effectiveness of psychotherapy" (p. 356).

Describe the basic principles of strengths-based CBT.

Like cognitive therapy, SB-CBT is empirically based. This means that (1) thera- pists should be knowledgeable about evidence-based approaches pertaining to client issues discussed in therapy, (2) clients are asked to make observations and describe the details of their life experiences so what is developed in therapy is based in the real data of clients' lives, and (3) therapists and clients collaborate Strengths are integrated into each phase of treatment in SB-CBT beginning with the intake interview. After reasons for seeking therapy are described and explored, the SB-CBT therapist expresses an interest in positive aspects of the client's life: "Thank you for telling me about the reasons you came to therapy. Even though this is a tough time for you, I wonder if there are some things that are going well in your life or that bring you happiness, even now. If you are willing to tell me about some of those things, it will help me know you more as a whole person." In Collaborative Case Conceptualization: Working Effectively With Clients in CBT, Kuyken, Padesky, and Dudley (2009) show how positive interests and strengths identified in early therapy sessions can provide a wealth of information to help ther- apist and client collaboratively integrate strengths into case conceptualization and treatment. SB-CBT therapists help clients develop and construct new positive ways of inter- acting in the world. The SB-CBT model for building and strengthening personal resilience can be used on its own or integrated with another evidenced-based CBT treatment for a diagnostic disorder (Padesky & Mooney, 2012). Three current applications for SB-CBT are as (1) an add-on for classic CBT, (2) a four-step model to build resilience and other positive qualities, and (3) the NEW Paradigm for chronic difficulties and personality disorders.

Differentiate REBT from CT with respect to how faulty beliefs are explored in therapy.

One of the strengths of REBT is the focus on teaching clients ways to carry on their own therapy without the direct intervention of a therapist. I particularly like the emphasis that REBT puts on supplementary and psychoeducational approaches such as listening to tapes, reading self-help books, keeping a record of what they are doing and thinking, and carrying out homework assignments. In this way clients can further the process of change in themselves without becoming excessively dependent on a therapist. Beck's Cognitive Therapy Beck's key concepts share similarities with REBT but differ in being empirically rather than philosophically derived, the processes by which therapy proceeds, and the formulation and treatment for different disorders. Beck made pioneering efforts in the treatment of anxiety, phobias, and depression. Beck demonstrated that a structured therapy that is present centered and problem oriented can be very effective in treating depression and anxiety in aBeck developed specific cognitive procedures to help depressive clients evaluate their assumptions and beliefs and to create a new cognitive perspective that can lead to optimism and changed behavior Padesky and Mooney's Strengths-Based CBT Beck's CT has been further expanded with Padesky and Mooney's strengths-based CBT approach. In addition to incorporating strengths at each phase of treatment, SB-CBT has successfully incorporated a wide range of modalities including imagery, metaphor, stories, and kinesthetic body experiences into the broad repertoire of CBT interventions. SB-CBT also provides models that extend CBT from evidence-based treatment of client problems to evidence-based models for developing positive qualities and client strengths. Instead of focusing solely on testing existing beliefs, SB-CBT offers systematic methods for helping clients construct new beliefs and behaviors that help realize their goals of "how they would like to be." Meichenbaum's Cognitive Behavior Modification Meichenbaum's work in self- instruction and stress inoculation training has been applied successfully to a variety of client populations and specific problems. Of special note is his contribution to understanding how stress is largely self-induced through inner dialogue. Meichenbaum's integration of the cognitive narrative perspective is a key strength of his therapy style. He is able to combine elements of the postmodern interest in stories clients tell with assisting clients in changing their cognitions, feelings, and behaviors by drawing on a cognitive behavioral conceptual framework. A contribution of all of the cognitive behavioral approaches is the emphasis on putting newly acquired insights into action. Homework assignments are well suited to enabling clients to practice new behaviors and assisting them in the process of learn- ing more effective coping skills. It is important that collaboratively created homework be a natural outgrowth of what is taking place in the therapy session. Ellis's REBT, Beck's cognitive therapy, Padesky and Mooney's strengths-based CBT, and Meichen- baum's stress inoculation training all place special emphasis on practicing new skills both in therapy and in daily life, and homework is a key part of the learning process. Clients learn how to generalize coping skills to various problem situations and acquire relapse prevention strategies to ensure that their gains are consolidated.

Understand how cognitive methods can be applied to change thinking and behavior. Also what is rational emotive imagery (rei)? Behavioral Techniques?

REBT practitioners usually incorporate a persuasive cognitive methodology in the therapeutic process. They demonstrate to clients, often in a quick and direct manner, what it is that they are continuing to tell themselves. Then they teach clients how to challenge these self-statements so that they no longer believe them, encouraging them to acquire a philosophy based on facts. REBT relies heavily on thinking, disputing, debating, challenging, interpreting, explaining, and teaching. The most efficient way to bring about lasting emotional and behavioral change is for clients to change their way of thinking (A. Ellis & Ellis, 2011, 2014). Here are some cognitive techniques available to the therapist Disputing irrational beliefs. The most common cognitive method of REBT consists of the therapist actively disputing clients' irrational beliefs and teaching them how to do this challenging on their own. Clients dispute a particular "must," absolute "should," or "ought" until they no longer hold that irrational belief, or at least until it is diminished in strength. Here are some examples of questions or statements clients learn to tell themselves when they dispute their irrational ideas: "Why must people treat me fairly?" "How do I become a total flop if I don't succeed at important tasks I try?" "If I don't get the job I want, it may be disap- pointing, but I can certainly stand it." "If life doesn't always go the way I would like it to, it isn't awful, just inconvenient." Doing cognitive homework. REBT clients are expected to make lists of their problems, look for their absolutist beliefs, and dispute these beliefs. Clients are encouraged to record and think about how their beliefs contribute to their personal problems and are asked to work hard at uprooting these self-defeating cognitions. Homework assignments are a way of tracking down and attending to the "shoulds" and "musts" that are part of their internalized self-messages. In this way, clients gradu- ally learn to lessen anxiety and to challenge basic irrational thinking. They often fill out the REBT Self-Help Form, which is reproduced in the Student Manual for Theory and Practice of Counseling and Psychotherapy (Corey, 2017). Their comments on this form can focus therapy sessions as they critically evaluate the disputation of their beliefs. Clients may be encouraged to put themselves in risk-taking situations that will allow them to challenge self-limiting beliefs. For example, a client with a tal- ent for acting who is afraid to act in front of an audience because of fear of failure may be asked to take a small part in a stage play. Work in the therapy session can be designed so that out-of-session tasks are feasible and the client has the skills to complete these tasks. Making changes tends to be hard work. Doing work outside sessions is of real value in revising clients' thinking, feeling, and behaving. Bibliotherapy. REBT, and other CBT approaches, can utilize biblio- therapy as an adjunctive form of treatment. There are advantages ofbibliotherapy, such as cost-effectiveness, widespread availability, and the potential of reaching a broad spectrum of populations. Bibliotherapeu- tic approaches have empirical support for a range of clinical problems, including the treatment of depression and many anxiety disorders (Jacobs, 2008). Because therapy is seen as an educational process, clients are encouraged to read REBT self-help books such as Rational Emotive Behavior Therapy: It Works for Me—It Can Work for You (A. Ellis, 2004a) and other books by Ellis (1999, 2000, 2001a, 2001b, 2005, 2010; A. Ellis & Ellis, 2011). Changing one's language. REBT rests on the premise that imprecise lan- guage is one of the causes of distorted thinking processes. Clients learn that "musts," "oughts," and absolute "shoulds" can be replaced by preferences. Instead of saying "It would be absolutely awful if ..." they learn to say "It would be inconvenient if ..." Clients who use language patterns that reflect helplessness and self-condemnation can learn to employ new self-statements, which help them think and behave differ- ently. As a consequence, they also begin to feel differently. Psychoeducational methods. REBT programs introduce clients to various edu- cational materials such as books, DVDs, and articles. Therapists educate clients about the nature of their problems and how treatment is likely to proceed. They ask clients how particular concepts apply to them. Clients are more likely to cooperate with a treatment program if they understand how the therapy process works and if they understand why particular techniques are being used (Ledley, Marx, & Heimberg, 2010 rational emotive imagery (rei), This is a form of intense mental practice designed to establish new emotional patterns in place of disrup- tive ones by thinking in healthy waysclients are asked to vividly imagine one of the worst things that might happen to them and to describe their disturbing feelings. Clients are shown how to train themselves to develop healthy emotions, and as their feelings about adversities change, they stand a better chance of changing their behavior in the situation. This technique can be usefully applied to interpersonal and other situations that are problematic for the indi- vidual. Clients who practice rational emotive imagery several times a week for a few weeks may reach the point where they no longer feel upset over these negative events Behavioral Techniques REBT practitioners use most of the standard behavior therapy procedures, especially operant conditioning, self-management principles, systematic desensitization, relaxation techniques, and modeling. Behavioral homework assignments carried out in real-life situations are particularly important. These assignments are done systematically and are recorded and analyzed. Homework gives clients opportunities to practice new skills outside of the therapy session, which may be even more valuable for clients than work done during the therapy hour (

Identify the basic principles of cognitive therapy.

The goal of CT is to help clients learn practical skills that they can use to make changes in their thoughts, behaviors, and emotions and how to sustain these changes over time. In cognitive therapy, clients learn how to identify their dysfunctional thinking. Once clients identify cognitive distortions, they are taught to examine and weigh the evidence for and against them. This process of critically examining thoughts involves empirically testing them by looking for evidence, actively engaging in a Socratic dialogue with the therapist, carrying out homework assignments, doing behavioral experiments, gathering data on assumptions made, and forming alterna- tive interpretations From the start of treatment, clients learn to employ specific problem-solving and coping skills. Through a process of guided discovery, clients acquire insight about the connection between their thinking and the ways they act and feel. Cognitive therapy is focused on present problems, regardless of a client's diag- nosis. The past may be brought into therapy when the therapist considers it essen- tial to understand how and when certain core dysfunctional beliefs originated and how these ideas have a current impact on the client's difficulties (Dattilio, 2002a). The goals of this brief therapy include providing symptom relief, assisting clients in resolving their most pressing problems, changing beliefs and behaviors that main- tain problems, and teaching clients skills that serve as relapse prevention strategies.

Understand Meichenbaum's three-phase process of behavior change.

cognitive behavior modification (CBM) focuses on chang- ing the client's self-talk. self-statements affect a person's behavior in much the same way as statements made by another person. A basic premise of CBM is that clients, as a prerequisite to behavior change, must notice how they think, feel, and behave and the impact they have on others. For change to occur, clients need to interrupt the scripted nature of their behavior so that they can evaluate their behavior in various situations.This approach shares with REBT and Beck's cognitive therapy the assumption that distressing emotions are often the result of maladaptive thoughts. REBT is more direct and confrontational in uncovering and disputing irrational thoughts, whereas Meichenbaum's self-instructional training focuses more on helping clients become aware of their self-talk and the stories they tell about themselves. Both REBT and CT focus on changing thinking processes, but Meichenbaum suggests that it may be easier and more effective to change our behavior rather than our thinking. Furthermore, our emotions and thinking are two sides of the same coin: the way we feel can affect our way of thinking, just as how we think can influence how we feel. "behavior change occurs through a sequence of mediating processes involving the interaction of inner speech, cogni- tive structures, and behaviors and their resultant outcomes" Phase 1: Self-observation. Clients learning how to observe their own behavior. When clients begin therapy, their internal dialogue is characterized by nega- tive self-statements and imagery. Phase 2: Starting a new internal dialogue. As a result of the early client- therapist contacts, clients learn to notice their maladaptive behaviors, and they begin to see opportunities for adaptive behavioral alternatives. Phase 3: Learning new skills. Clients learn to interrupt the downward spiral of thinking, feeling, and behaving, and the therapist teaches clients more adaptive ways of coping using the resources they bring to therapy.

Describe how the A-B-C model is a way of understanding the interaction among feelings, thoughts, and behavior.

rational emotive behavior therapy (REBT) was the first of the cognitive behav- ior therapies, and today it continues to be a major cognitive behavioral approach.A basic assumption of REBT is that people contribute to their own psychological problems, as well as to specific symptoms, by the rigid and extreme beliefs they hold about events and situations. REBT is based on the assumption that cognitions, emotions, and behaviors interact significantly and have a reciprocal cause-and-effect relationship.REBT is based on the premise that we learn irrational beliefs from significant others during childhood and then re-create these irrational beliefs throughout our life- time. We actively reinforce our self-defeating beliefs through the processes of auto- suggestion and self-repetition, and we then behave in ways that are consistent with these beliefs. The A-B-C framework is central to REBT theory and practice.This model provides a useful tool for understanding the client's feelings, thoughts, events, and behavior A-is the existence of an activating event or adversity, or an inference about an event by an individual B-is the person's belief about A, largely creates C, the emotional reaction. C-s the emotional and behavioral conse- quence or reaction of the individual; the reaction can be either healthy or unhealthy. A (the activating event) does not cause C (the emotional consequence). D-After A, B, and C comes D (disputing). Essentially, D encompasses methods that help clients challenge their irrational beliefs. There are three components of this dis- puting process: detecting, debating, and discriminating. Clients learn to discriminate irrational (self-defeating) beliefs from rational (self-helping) beliefs ( E-a new effective philosophy, which also has a practical side. A new and effective belief system consists of replacing unhealthy irra- tional thoughts with healthy rational ones. "Homework" can enhance and maintain these therapeutic gains and personal insights.