Cognitive-Behavioural Therapy (CBT) is a general term for a school of psychotherapy that has developed over the last sixty years. A great deal of carefully constructed scientific research has demonstrated that it is effective in dealing with a variety of psychological problems, including depression, anxiety, panic disorder, phobias (such as social phobia), obsessions and compulsions and problems caused by trauma. It is relatively brief (usually 6 to 20 sessions), problem focussed, and built on collaboration between patient and therapist. It is now used to deal with a variety of common problems, including work stress, excessive worry, health anxiety and low self-esteem.
Cognitive-Behavioural Therapy begins with the creation of a problem list. Client and therapist work together to decide which problem of the client’s is most distressing, and therapy focuses on relieving that distress and teaching the client new skills to deal with it. Therapist and patient will then develop a formulation, a model of what factors are causing the problem that can guide the therapy process. The therapy will then explore how the client’s thoughts, actions and feelings interact to create the problem or problems that the client wants to address. At every step of the way, collaboration is the key to therapy success.
FEELINGS AND HOW TO MANAGE THEM
“I can’t help what I feel!” This statement is in part certainly true. We cannot will ourselves to feel a certain way. You cannot, for example, tell yourself to like someone when you don’t. On the other hand, there are many things we can do to influence our moods and feelings. The first step is to decide that we would like to feel differently about a person, activity or situation. Imagine someone with a fear of high places. If this fear is mild and causes the person few problems, there may be no reason why he should wish to change it. But now imagine a woman with such a fear who has a daughter living in a tower block whom she cannot visit. She now would have a strong motive for wishing to tackle her fear. It is the CBT therapist’s job to help her make desired changes. This can generally be done by examining her thoughts and actions. She will probably have frightening thoughts about high places that can be explored, and her daily life may contain a number of strategies, large and small, which help her to avoid dealing with her fear. These are referred to as Safety Behaviours. Client and therapist together can set up and carry out behavioural experiments to test these strategies and see if there are more effective ways of coping. The most important predictor of people’s ability to change unhelpful feelings is their desire to do so.
THOUGHTS: THE IMPORTANCE OF WHAT WE THINK
In the term Cognitive-Behavioural Therapy, the word “Cognitive” refers to thoughts. A basic, and not very surprising, theme in CBT is that what we think is very important in determining how we feel and what we do. The ability to think is a key part of what makes us human, and this ability has many positive features. Consider for example the ability to solve problems or to avoid harmful situations. But thinking can also lead to problems when our thoughts lead us in unhelpful directions. Research shows that many emotional problems are characterised by particular thought patterns. Depressed people often suffer with self-critical and pessimistic thoughts, like “I’m such a waste of space” or “Nothing will go right for me”. Anxious people often suffer from thoughts of danger: “Wouldn’t it be awful if I made a fool of myself?” People who suffer from panic attacks will often think that they are dangerously ill: “I might be having a heart attack!” CBT does not deal with these thoughts by using “positive thinking” (“Of course you’re not having a heart attack!”) because sufferers don’t usually find this helpful. Instead, it respects the client by taking his or her thoughts seriously: “You think you’re a waste of space. What are you’re reasons for believing that?” Clients are taught to examine and test their thoughts, and to base their actions on reasoned choices. Often a Thought Record is used to help people look at their thoughts, examine them, and come up with a reasonable way of looking at any given situation. Another very important tool is the Behavioural Experiment, where client and therapist devise ways of testing unhelpful thoughts. Once she has developed this skill, he or she can continue to use to after therapy has finished, which is one reason why CBT has been shown to lower the rate of relapse for many emotional problems.
ACTIONS: THE IMPORTANCE OF WHAT WE DO
In the term Cognitive-Behavioural Therapy, the word “Behavioural” refers to actions. An important finding of CBT research is that unhelpful thoughts are often reinforced by unhelpful actions, and that these can work together to make the sufferer feel worse. At the same time, positive actions can often raise mood, reduce fears and worries and help people to solve their problems.
Depressed people often feel that their problems cannot be solved. As a result, they will feel tired and lethargic and stop doing a variety of things. Often, a simple step such a making a checklist of necessary activities can be very helpful. Clients can also be helped to see that a variety of activities can lift the mood, ranging from regular exercise to pursuing an interest or hobby. The therapist will sometimes suggest keeping a record of the week’s activities, which can then be used to increase positive activities and decrease negative ones; this is called an Activity Schedule. The term Behavioural Activation is often used for this form of treatment, and there is strong evidence that it can be very helpful.
Anxiety sufferers will often avoid a variety of things. It is often found that avoidance will grow over time, and that this in turn can make the anxious person even more fearful. Sometimes this avoidance will take a subtle form, which can be referred to as a Safety Behaviour. This is defined as something that makes us feel safer without actually being safer. For example, a person with a fear of travelling on public transport might practice shutting his eyes and pretending not to be on a bus. Aside from the risk of missing his stop, this behaviour might, over time, make his fear worse. In CBT client and therapist work together to identify unhelpful behaviours, and this is often a key element of treatment.
Distressing images can play an important role in a variety of problems. Someone who suffers from anxiety may experience frightening images of some feared; for example, someone with social phobia might experience a vivid image of himself being socially humiliated. People who have suffered with trauma may experience flashbacks, vivid images of an accident or distressing experience, combined with the feeling that event is actually happening again. Someone with depression might have an image of herself failing in some way and being revealed to be a worthless person. Because of the important role of images in many disorders, assessing and modifying them can be an important part of CBT therapy.
CBT is intended as a problem solving therapy that focuses on factors that maintain the client’s problems in the present. However, it always takes account of early experiences, as these are important in shaping everyone’s character. Early experiences are always part of the Formulation developed as part of CBT, but the degree to which they are a focus of therapy may vary. For some clients, work may focus almost entirely on the present, but for others exploring issues in the past may be a very important part of treatment, especially if some past trauma is playing an important part in maintaining current problems. As always in CBT, patient and therapist collaborate, so that the client’s wishes and preferences will play the key role in determining priorities in therapy.