Cognitive Behavioural Therapy

Cognitive Behavioural Therapy (CBT) is a model of psychotherapy that emphasizes the important role of thinking in peoples' emotional and mental states. Cognitive-behavioral therapists work from the idea that an individual's thinking (cognitions) causes him/her to feel and act the way they do.

Therefore, it is important to identify the thinking that is causing unwanted feelings / behaviors and to learn how to replace this thinking with thoughts that lead to more desirable reactions. It is also important to carry out actions (behaviour) that is consistent with helpful and rational (functional) thoughts as well as behaviour that influences dysfunctional (negative, distorted) thoughts - that is, if you behave in a certain way you will start to believe (think) it.

CBT is a general classification of psychotherapy, and several approaches to CBT fall within the classification. Cognitive therapies focus on identifying and challenging dysfunctional thoughts. These include negative automatic thoughts, unhelpful rules and assumptions, and irrational core beliefs (Ellis, 1994, Beck, 1995). Behavioural approaches aim to modify behaviour through changing the consequences of behaviour. This includes manipulation of events in daily functioning, and may include relaxation, assertiveness and other skills training applicable to real-life and current situations. A CBT therapist will typically work on both thinking and behaviour, recognizing the bi-directional relationship between them and focusing on interventions to address both simultaneously.

A CBT approach to the treatment of psychological problems is arguably the most widely used psychotherapeutic model in the Western World. It has been extensively researched and found to more effective than drug treatment alone in treating depression and anxiety, with also now evidence for its value in treating other disorder types, such as bipolar, and schizophrenia. Knowing that psychiatrically ill patients can compensate for their biological and psychological vulnerabilities through cognitive strategies gives CBT therapists encouragement. CBT is valued by both practitioners and health funders for its structure, timeframes, and suitability for evaluation.

10 constructs and features of CBT in practice are as follows:

  1. It is based on the Cognitive Model of Emotional Response
    As noted, CBT is based on the notion that thoughts, and deeper down, beliefs, cause feelings and behaviors, not external things, like people, or situations/ events. Different people react in different ways to the same situation. If a person can change the way they think they will feel / act better even if the situation does not change.
  2. It is brief or time-limited
    The average number of sessions clients receive (across all types of problems) is only 16. Some practices work on as little as a 6 session model. Other forms of therapy, like psychoanalysis, can take many years. What enables CBT to be briefer is its instructional nature and the fact that it makes use of homework assignments (see below).
  3. Therapeutic relationship is not the main focus (though necessary)
    Techniques and strategies are to the forefront in CBT. Some forms of therapy assume that the main reason people get better in therapy is because of the positive relationship between the therapist and client. CBT therapists believe it necessary to have a trusting relationship, but that is not enough.
  4. Its based on stoic philosophy
    CBT therapy does not tell people how they should feel. However, most people seeking therapy do not want to feel as they do. CBT teaches the benefits of coping in healthy ways with undesirable situations. It also emphasizes the fact that undesirable situations exist and if a person gets upset about a situation, there becomes a second problem, the triggering problem, and being upset about it.
  5. The Socratic Method is used
    There is a focus on asking questions, and on encouraging clients to ask questions of themselves, like, "How do I really know that they dislike me?" "Could they not be saying much to me for another reason?" Clients assume an active role in changing their dysfunctional thinking and gaining relief from symptoms.
  6. Its structured and directive
    A specific agenda is developed for each session. Specific techniques / concepts are taught during each session. The focus is on directing clients to achieve goals they have set. However, CBT therapists do not tell a client ‘what to do’, rather, they teach a client 'how' to do.
  7. An educational science-based model is followed
    CBT is based on the scientifically supported assumption that most emotional and behavioral reactions are learned. Therefore, the general aim of therapy is to assist clients unlearn their unhelpful reactions and to learn a new way of being. While CBT therapists do not present themselves as "know-it-alls" the assumption is that if clients knew what the therapist had to teach them, clients would not have the emotional / behavioral problems they are experiencing. A CBT therapist focuses on presenting information to a client that is based on logic and a scientific basis. They aim to subject themselves to the same approach they encourage from clients, that is to seek evidence for their beliefs and rationale for their actions.
  8. It relies on the Inductive Method
    Considers rational thinking to be based on fact, and focuses on clients questioning assumptions and looking at thoughts as being hypotheses to be questioned and tested. If it is found that hypotheses are incorrect (because of new information), then a person can change our thinking to be in line with how the situation really is.
  9. Homework is essential
    CBT therapists recognize that change can not occur in a limited number of therapy sessions. Progress would take a very long time if a person were only to think about the techniques and topics taught for one hour per week. Homework is an important part of the treatment approach and reading is assigned, along with practice for techniques learned.
  10. Focus is on the present and future
    CBT therapists focus on how a person is thinking and behaving today. The past is looked at for thinking patterns and previous functioning, and to identify the origins of problems. However, solutions to problems are in the here and now, and although links are made with the past, therapy does not take the person back there to re-experience events from childhood, etc. Current and everyday examples are used as the focus of techniques and strategies. Current problems are worked on and solved though reframing of past events in today's context.

Techniques and Procedures

As noted above, CBT therapeutic intervention involves a number of techniques and procedures to help a person change how they think, feel, and act.

Awareness of thinking is a fundamental skill that a client needs to grasp early on as it precedes any work on change. Often clients do not think about their thinking, so typically the first point of instruction is in the process of thinking and its links to emotion and behaviour. A model showing the importance of thinking is usually outlined with clients as the first procedure in CBT. They then go on to keep Thought Records as a way of monitoring their thoughts.

The 5 part model (Padesky and Greenberger, 1995) is most often used. Other diagrams highlight the importance of thinking as the component that occurs first and causes emotions and body sensations. Not all therapists agree that thoughts occur first and present the below diagram without temporal relationships. The 5 part model is as follows:

A 'Situation' - a problem, event or difficult situation leads to:

  • Thoughts
  • Emotions
  • Physical feelings
  • Actions (Behaviour)

Each of these areas can affect the others. How a person thinks about a problem can affect how they feel physically and emotionally. It can also alter what they do about it.

Example:

Situation: John has a bad day, feels fed up, so goes out shopping. As he walks down the road, a woman he knows walks by and apparently ignores him.

  Unhelpful Helpful
Thoughts She ignored me - they don't like me She looks a bit wrapped up in herself - I wonder if there's something wrong?
Emotional: Feelings Low, sad and rejected Concerned for the other person
Physical: Stomach cramps, low energy, feel sick None - feel comfortable
Action: Go home and avoid them Get in touch to make sure they're OK

 

The following diagram is often used with clients:

The diagram highlights how a "vicious circle" can occur and make a person feel worse if they start to believe unrealistic and unhelpful things about themself. This happens because, when distressed, a person is more likely to jump to conclusions and to interpret things in extreme and irrational ways.

In addition to explaining the relationship between thoughts and feelings and behaviour, the link between thoughts and deeper underlying core beliefs is also often explained. It can be helpful to develop with a client a cognitive map or case conceptualization of the cause of their current thinking and how it developed as a problem for them (Beck, 1995).

A general procedure/ technique utilized with clients to have them think more rationally is to follow a hypothesis-testing approach and have them collect evidence for their thinking. Clients are guided to test their assumptions as if they were a scientist, researcher, or detective. They are encouraged to prove that the situation is like they think it is, and can suspend upsetting themselves while collecting evidence. For instance, to test whether they are not liked, they can record information supporting that, eg, "they never say hello to me"; and information against, "they never say hello to anybody", "they usually say hello to me", "they gave me present last year", etc. Behavioural experiments can also be useful. This involves creating a situation to test the assumption. For instance, going and talking to the person of interest and seeing how they react in the interaction, perhaps even asking them how they feel about them. Alternatively, it may be useful to watch how other people react to the same behaviour with the person of interest. At a deeper level with beliefs, such as "I am loser", information collected for evidence may relate to successes achieved, comments of others, and/or day by day sampling of facts (as opposed to selected memories) etc.

Identifying cognitive distortions a person may have is a useful way to increase insight and commitment to change. Distortions in thought are common and varied. Commons ones include; catastrophizing, discounting the positives, over-generalization, personalization, should statements, labeling, and all or nothing thinking. CBT therapists get clients to label their distortions as well as to verbalise or record hot cognitions and negative automatic thoughts – thoughts that frequently readily upset them – and trigger strong emotional reactions (Padesky and Greenberger, 1995).

The heart of CBT involves Cognitive Restructuring in conjunction with behavioural activity. Techniques that are applied to assist the client to think about things in different more helpful ways include:

  • Disputing or Challenging irrational and/ or unhelpful thoughts though self-talk of Alternative Interpretation
  • Advantages and disadvantages; cost-benefit analysis of continuing to think same way
  • Self talk of positive adaptive statements; Affirmations
  • Reframing experiences
  •  Resynthesizing Critical Life Events, Life Themes, Early Recollections, and Family Beliefs

For explanations and detailed descriptions of the above techniques see Ellis (1994) and McMullin (2000).

Common behavioural methods include Goal Setting; Relaxation and Breathing training; Social Skills Training in Assertiveness and Communication, using Role plays; Imagery/ Visualization, and Exposure to fear situations.

References

  • Beck, J. B. (1995). Cognitive Therapy: Basics & Beyond. Guilford: New York
  • Ellis, A. (1994). How to keep people from pushing your buttons. Citadel: New York.
  • McMullin, R. E., (2000). The New Handbook of Cognitive Therapy Techniques. Norton: New York
  • Padesky, C. A., & Greenberger, D. (1995). Clinician’s Guide to Mind over Mood. The Guilford Press: London.

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About Us

Barry Kirker, Clinical Psychologist, has established South Auckland Psychology to provide the people of South Auckland with access to responsive, professional and skilled psychological assessments and treatments.
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