Cognitive Behavior Therapy

What is Cognitive Behavior Therapy?

Sometimes people occasionally experience thoughts, images or ideas that can become an obsession or preoccupation. These intrusive or toxic thoughts can be quite disturbing and evoke all kinds of negative feelings. When people have this persistent stream of negative thoughts, they can experience anxiety, panic, or a deep depression.

Cognitive Behavior Therapy, or CBT, is a kind of psychological treatment that is based on the concept that negative thoughts can lead to negative feelings that can lead to non-productive or maladaptive behaviors. The first step at addressing your behaviors of avoidance, immobilization or isolation is to change your dysfunctional or obsessional thought patterns.

CBT is based on behavioral outcome research that compares other treatments or no treatment to cognitive behavioral strategies. The experimental data tells us what specific tools or strategies have been found to be most effective in managing the problems for a variety of psychological conditions.

Treatment is then a partnership between the therapist and client. At the first session, clients are asked to come up with a list of goals or objectives for treatment. The sessions are then personalized for each individual client’s problem list of target behaviors or goals for treatment. For example, if I have social anxiety related issues and I have been avoiding social situations, I might want to attend more functions at work or at school, I may want to strive for a lower overall level of anxiety or distress, I might want to increase my assertiveness and my communication skills. A treatment protocol is created with the client’s input and homework can be assigned to reinforce the skills and build the positive behaviors outlined in the sessions. CBT is usually time limited and can be completed in 3 – 6 months. A lessening in the intensity and frequency of the negative or problematic symptoms can be accomplished in as little as 6 – 8 weeks.

What are the Building Blocks of CBT?

Cognitive Therapy - The cognitive portion of CBT is built on an approach founded by Dr. Donald Meichenbaum (Cognitive Behavior Modification), Dr. Albert Ellis (Rational Emotive Behavior Therapy or REBT) and Dr. Aaron Beck (Cognitive Therapy). Dr. Meichenbaum focused on identifying one’s negative internal dialogue in order to change unwanted behaviors. Dr. Meichenbaum viewed behavior as an outcome of our own irrational self-talk.

Dr. Ellis developed REBT in the mid-1950s as an alternative to psychoanalysis, which he felt was time-consuming and ineffective. Dr. Ellis’ REBT suggested that people’s negative or damaging beliefs strongly affected their emotional functioning. Certain illogical or toxic beliefs made people feel depressed, anxious or angry and led to self-defeating behaviors.

Dr. Beck developed cognitive therapy as a way to treat depression in the 1960s. Dr. Beck worked with depressed clients and found that they experienced an automatic chain of negative thoughts that appeared to occur spontaneously. Dr. Beck labelled these cognitions “automatic thoughts” and he found that their content fell into three categories - negative ideas about the self, the world, and the future.

Cognitive theorists helped clients recognize that they may be having a series of ongoing irrational or dysfunctional thoughts. The first step at managing their negative thoughts is to write them down as they happened. In this way, client can learn to recognize exactly what they are thinking including the frequency and intensity of those thoughts. How anxious or how depressed do the troubling thoughts make a client feel? Once the negative thoughts are identified, the client and therapist can then start to identify patterns or themes for their negative thinking.

Behavior Therapy – The behavioral component of CBT are the actions or behaviors we can address to resolve conflict or reduce one’s anxiety or depression. This process begins by identifying the target behaviors or set of goals that a client wants to change because of the difficulties or conflicts they may be experiencing in their lives. The therapist and the client then work together and look for a history of the problem. What is happening in my life that continues to work against me or cause me conflict or distress? Once the particular aversive stimuli or antecedents are identified that might be causing the problem, the client can learn specific tools to reduce or eliminate those unwanted symptoms in frequency and intensity.

One strategy unique for the treatment of anxiety is called exposure. Exposure therapy gradually exposes clients to what is frightening to them and it helps them cope with their fears associated with a particular issue. One might for example, have a fear of flying. The difficulty getting on an airplane or the inability to take a trip because of crippling anxiety would certainly contaminate the travel experience.

Exposure therapy can be used very successfully for a fear of flying and other phobias to reduce the anxiety and worry associated with a particular area of concern. A fear hierarchy or ladder of fears is created and the client is gradually exposed to what is causing them anxiety. Stressors are identified and given a value associated from the lowest level to the highest level of fear or distress. A number is given to each step or level of the hierarchy. Anxiety is measured on a level from 0 to 100, with 0 being the lowest and 100 being the highest, and 30 to 40 being the so called “normal level of anxiety”. The client does not move to a higher level of anxiety until they are able to achieve a level of calm at the lower level of anxiety.

For example, for someone with a fear of flying it might be suggested that they first drive past an airport, allowing themselves to experience the anxiety experienced with this behavior, then by practicing their breathing and relaxation exercises, they reduce their anxiety to a so called “normal level” of 30-40. The client may then move to the next step of the fear hierarchy or expose themselves to a higher level of anxiety and perhaps stand inside the airport or even take a short flight. Clients can successfully train themselves to fly without any anxiety or with a reduced level of anxiety and fly successfully with the completion of a fear hierarchy. The lessening of the anxiety is achieved through practice with diaphragmatic or deep breathing, deep muscle relaxation, and visualization or guided imagery.

Prolonged exposure is designed to treat post-traumatic stress disorder or PTSD. PE teaches the client to gradually approach trauma-related memories, feelings, and situations that have previously been avoided following a traumatic event. PE allows the client to help themselves face their fears and associated anxiety. PE must be done very carefully so as not to re-traumatize the client. It is imperative to engage in treatment with a licensed psychologist who has the knowledge and specialized training to work with clients who have experienced traumatic life events.

Post-Traumatic Stress Disorder or PTSD is a mental health condition that is triggered by a experiencing a terrifying event or watching it happen firsthand. The symptoms of PTSD may include flashbacks, nightmares and severe disabling anxiety including having uncontrollable thoughts about the event. Exposure therapy and desensitization are used for clients with PTSD.

Exposure therapy helps the client face the distress and anguish associated with the trauma. Exposure therapy for PTSD must be done very cautiously, it is important that the client is not re-traumatized. For some clients, memories of a trauma can be confronted all at once and a skilled therapist can employ a strategy called flooding. Desensitization is another technique utilized by a trained therapist working with a survivor of trauma. Desensitization is a technique where one starts with a less upsetting life stressor and works up to the most severe trauma utilizing relaxation exercises one piece of the trauma at a time. When a client has an established relationship with their therapist and has learned to trust them, they can begin talking about the details of their traumatic life events and confront their previously fear inducing conditions slowly and carefully, and can decrease their PTSD related symptoms and thus regain control of their lives.

An experienced therapist can determine which type of treatment strategy would work best for the client and their particular issues. The client is never forced to take part in an intervention that they feel tentative or are fearful about. The therapist who works with an anxious client needs to discuss the different kinds of techniques that might be utilized and tell the client exactly what they involve. The client therefore continues to feel in control of their circumstances.

Mindfulness and Meditation - CBT therapists are fortunate to have the benefit of wellness and spiritual techniques such as mindfulness and meditation as tools for their clients. Mindfulness and meditation can give clients the emotional distance and perspective they may need in order to learn to rationally respond to their negative or toxic thoughts. Mindfulness is a strategy that clients can use to raise their consciousness to what is being experienced in the present with both their bodies and minds. Mindfulness without judgment and with acceptance can decrease the anxiety or stress for the client. This strategy can allow individuals to take control of their responses to potentially stressful life events. Clients learn to manage stressors in a more objective manner. Their physiological or bodily response to their anxiety is diminished as well.

How Does Cognitive Behavior Therapy Work?

Cognitive Behavior Therapy or CBT helps clients learn to change their dysfunctional thought patterns by replacing negative or maladaptive thoughts with more positive or adaptive ones. A client works together with their therapist to learn how to think more positively and consequently behave in a more positive manner. CBT is a great therapeutic technique for busy people who may have a limited amount of discretionary time. CBT is goal directed and time limited. Significant results are often seen in as few as 6 – 8 sessions. People start feeling better quickly!

Cognitive Behavior Therapy is a collaborative process between the client and the therapist. A client’s specific goals for treatment or their target behaviors are identified at the initial meeting. This outlines for both the client and their therapist what thoughts and behaviors might be problematic for the client and therefore needs to be addressed. The therapy sessions can provide concrete tools for the client to modify their own disabling or stressful behavior. Suggestions are given to the clients to practice strategies at home to reinforce the skills they are learning in their sessions. Examples of this kind of “homework” include asking the client to first write down their negative thoughts. Clients are then asked to rationally respond or detoxify their negative thoughts. It can also be suggested that clients practice the relaxation and diaphragmatic breathing techniques at home that are done in the sessions. Clients are also taught to practice these new techniques in actual anxiety provoking situations as they happen to them in real life, in order to further reinforce these skills.

What Problem Areas Can Benefit from CBT?

  • Anxiety disorders including Panic Disorder, OCD, Phobias, PTSD and Social Anxiety Disorder
  • Psychological factors that may be contributing to medical issues
  • Depression
  • Relationship Issues
  • Body Dysmorphic Disorder
  • Eating Disorders
  • Pregnancy Loss and Infertility
  • Grief and Bereavement
  • ADHD
  • Insomnia and other sleep difficulties
  • Chronic Pain
  • Smoking Cessation
  • Substance Abuse