Cognitive Behavioural Therapy – An Introduction
Cognitive Behavioural Therapy (CBT) is a type of psychotherapy which aims to help people alleviate problems by understanding and modifying unhelpful patterns of thoughts, emotions and behaviour. It has been shown to be an effective treatment for a wide range of problems including depression, anxiety, panic, obsessive compulsive disorder (OCD), Post-traumatic stress disorder (PTSD) and eating disorders.
Since it’s inception in the 1970’s by Dr Aaron Beck, CBT has developed into a broad discipline with a wide variety approaches, each still with the focus of understanding emotional distress from the perspective of problematic thoughts and behaviours.
The role of Thoughts in CBT
Beck’s original concept of CBT suggested that for us to experience a particular emotion, we need to be thinking about, or appraising, an event in a very particular way. Thoughts are always making opinions about our experience – depending upon what the thoughts says about our experience, we will feel different types of emotions. The diagrams below illustrate this further:
Appraisal 1
Appraisal 2
Appraisal 3
We can see in the above examples that although the initial event is the same, how each event is interpreted by the thought leads to a different emotional response.
In the first example, the thoughts centre around the individual not matching up to his partner’s expectations in some way, leading to a sense of sadness and despondency. The “Negative Automatic Thought” about the trigger event leads to sadness.
The second example sees the event being appraised as a criticism of the individual’s performance and as such leads to a sense of anger and hostility. Lastly, a caring and empathic emotional response is generated as a consequence of an appraisal which views the partners comment as being a genuine expression of tiredness.
The point here is that different emotional states will be arrived at based upon how our minds evaluate events. In the examples above, we don’t really have enough information to decide whether the partner is being genuinely tired, critical or sarcastic but we do know that when an emotional state is arrived at, it can tend to overwhelm and inhibit more rational thinking leading to further emotional distress.
Beck’s Cognitive Therapy aimed to empower the individual with the skills to identify their thoughts and evaluate their accuracy or benefit in relation to triggering events, thereby creating the potential to reduce or modify emotions in context. For example, in the example in “appraisal 1”, the thoughts “she thinks I’m not doing enough, I’m letting her down” can be subject to scrutiny. Where is the evidence that the partner thinks that he’s not doing enough? Has she actually said so, or is he jumping to a conclusion? Before we commit to believing a thought, which may lead to some variety of negative emotional experience, we at least owe it to ourselves to ensure that it is accurate, right? Cognitive Behavioural Therapy allows us to develop the skills to do this.
Behaviours
Identifying and modifying unhelpful thoughts and beliefs are one aspect of traditional CBT, but we are also interested in understanding how behaviours serve to maintain emotional distress. Expanding upon the examples given above, what do you think would be the behavioural responses to each of the appraisals and emotional reactions? Here are some possibilities…
Here we can see that the behavioural response to the partners comment is to reduce contact with her (to reduce the potential for further perceived criticism) and to commit more to the life area which may guarantee less of a sense of failure, his work.
Of course, this response is not necessarily ideal in that, a) the individual reduces the opportunity to find out if they were being criticised in the first place, thus maintaining the belief, b) they reduce opportunities to experience positive events within the context of being a new dad and c) the problem of the partner being tired remains unresolved, potentially contributing to future stressors.
It is clear to see here that the behavioural responses adopted in situations such as these are fundamental in establishing whether a problem gets resolved or increased. CBT is interested in understanding how behaviours serve to maintain problems and negative emotional states
The tools of Cognitive Behavioural Therapy
Rather than have you spend months sitting in a chez lounge, speculating upon how how a rorschach image reminds you of that time your dad stopped you from having ice-cream when you were 6 years old, Cognitive Behavioural Therapy aims to equip you with the skills to deal with your problems in a much shorter time frame.
Many treatment plans within CBT aim to achieve sustainable recovery for most patients within 12 to 16 sessions of therapy. Of course, some people may require a few more, others a few less, but the main idea is that you are able to see if the tools of CBT are beneficial to you and your problems relatively quickly, rather than spending “years in therapy.”
Further, as CBT is a skills based therapy, it is a key treatment goal for you to become knowledgable and skilled in the techniques of the treatment, so that in effect, you can become your own therapist. This means that, when therapy ultimately ends, you can continue to assess and modify say, antidepressant behaviours, or to continue to restructure your thinking. Life is full of events which test our resilience – CBT aims to equip you to deal with this.
A generic CBT treatment plan may look something like this:
1. Cognitive Behavioural Therapy Assessment
This is where all of the relevant information relating to the problem (or problems) is elicited from the patient. This would include a list of symptoms, often divided into cognitive (e.g., thinking, attention, memory), behavioural (e.g., avoidance, reduced activities, checking), emotional (e.g., sadness, fear) and physiological (e.g., reduced motivation, disturbed sleep), and related situational triggers.
Relevant personal history and the development of the problem are also areas which are assessed as is the impact of the problems upon the individuals current level of functioning. Assessment of risk is also incorporated.
Often, questionnaires (also called psychometrics) will be used to assess the baseline of symptoms at the start of therapy. For instance, a common questionnaire used to assess depression symptoms is the PHQ9. Used at the start , middle and end of treatment, it is possible for the therapist and patient to establish how well recovery from depression symptoms is being achieved
2. CBT Formulation
This stage of treatment focuses upon gathering the data collected in the assessment and developing a framework of how the problem “looks” for the purpose of CBT. If you look at the illustration above which links together the thoughts, emotions and behaviours of the patient in response to his partners comment, this is an example of a “3 systems” maintenance formulation.
We have a representation of how the individuals thoughts, emotions and behaviours represent themselves and how they are related. Based upon this formulation, we may then decide to target any one of the areas with a particular type of intervention, and anticipate that this would have an effect upon the other areas of the problem.
There are different approaches to formulation which may be used depending upon the particular type of problem. Typically, it is best practice to formulate using a “disorder specific” treatment model if one is appropriate to the problem, and then to use a more generic formulation approach if not. Whatever approach is used, the real aim of formulation is for the patient and therapist to develop a shared understanding of the problem, from which to guide treatment interventions.
3. CBT Treatment
Based upon the outcomes of assessment and formulation, conclusions about treatment interventions can be made. There are many different types of treatment intervention which can be used within Cognitive Behavioural Therapy, and these will be talked about elsewhere on the site, but for the moment I want to talk about just two; behavioural activation and cognitive restructuring.
Behavioural activation (BA) is a powerful treatment for depression which enables the individual to understand how particular behaviours can serve to maintain or alleviate their low mood. Depression is often characterised by changes in activity levels, often seen as avoidance or the patient simply not doing the things that they used to do. BA aims to reverse this pattern, increasing the individuals opportunities to access meaningful, positive events and to develop more helpful problem solving strategies.
Cognitive restructuring (CR) teaches an individual to identify and modify their “negative automatic thoughts.” When we are depressed, our thinking tends to be more negative in nature, more generalised and more critical. By learning to identify these thoughts and hold them up to some degree of scrutiny to test how truly valid they are, we are able to remove some of their hold upon us, thus leading to improved mood.
CR then focuses upon developing more accurate thoughts which we would then aim to test out using a behavioural experiment. In all of this, we are not necessarily looking to point out whether or not the patient’s thoughts are simply right or wrong, but to kickstart the process of questioning them (rather than taking them as gospel truth) and re-learn new perspectives.
In both of the above interventions, self-monitoring is an integral part of the treatment. This is typically done using a type of diary or record sheet, but can also be done using newer technology such as audio or cameraphone. In addition to gaining access to your patterns of thoughts or behaviour, a key benefit of self-monitoring is that it makes content become less automatic, that is, we become more empowered to look at this content subjectively rather than taking it for granted. Another step on the way to becoming your own therapist!
4. Relapse prevention
At some stage, you will hopefully have recovered enough to end therapy – but this doesn’t mean that the work just stops! The skills you have spent time developing need to become integrated into your overall programme of self care. This is what we call relapse prevention.
The sad truth of the matter is that, for most of us, life can frequently be a challenge. There are always going to be curveballs thrown at us for which we need to decide the most appropriate and helpful way for us to respond. Relapse prevention aims to get together all of the skills and strategies that have worked for you within therapy and plan how you might be able to implement them in future.
When I work with people on relapse prevention, I encourage them to schedule a regular self-review day on which they can take to time out to purposefully review their mood and assess how they may have dealt with situations in a different way, or to plan how they can use their new skills with a forthcoming challenge.
We all have our particular vulnerabilities, or “red flag”, scenarios that seem to trigger particular strong responses. By spending time identifying potential red flags during relapse prevention, we are better able to plan and implement strategies which will aid us in our longer term recovery.
George Maxwell is an Accredited Cognitive Behavioural Therapist and director of Access CBT UK.
He specialises in the treatment of Male depression in the post-natal period but also has extensive skills in working with PTSD, Anxiety disorders, OCD and Panic. If you would like to arrange individual therapy with him (either face to face or via Skype), or would like to receive information and updates relating to New Dad Depression then feel free to contact him at enquiries@accesscbt.co.uk or follow on twitter @newdad_depressn.