Ever wondered why people have different reactions to situations? Like why are some people petrified to talk in front of others, whilst others seem carefree and confident. Or why do some people have a fear of snakes whilst others keep snakes for pets! Or why do some people suffer with anxiety and depression? Cognitive behavioural therapy provides us with a theory that explains these individual differences in behavior and emotions. But more importantly, CBT provides us with an understanding of the underpinnings of anxiety and depression AND a framework on how to help people overcome anxiety and depression. So if you visit a psychologist and they offer CBT treatment, what exactly is it and what will you be doing? This blog will provide you these answers.
Cognitive behavioural therapy focuses on the relationship between situations, what we think (thoughts or cognitions), how we feel (emotions), and what we do (behavior). Our appraisals of events that happen (cognitions), influence how we feel (emotions), and what we choose to do (behaviours) in response to those thoughts and feelings. Ths is known as the cognitive model.
For example, if I was faced with a snake (situation), I would make an appraisal of the snake as being threatening or non-threatening to me. If I perceived the snake to be a threat (thought), I am going to feel anxious (emotion) and in response to thinking I’m not safe and feeling anxious, I am probably going to RUN (behaviour)!!! This is an obvious example of the links between situations, thoughts, feelings and behaviours and lots of people may react in the same way. What about a not so obvious reaction?
Why do some people feel anxious around other people? Well, if I suffered with social anxiety and I was faced with a group of people (situation), I might make an appraisal that a group of people are threatening to me and the thought might be “what if they think I’m stupid” (thought) and then I am going to feel anxious (emotion). In response to these thoughts and emotions I might avoid talking with the people in the group (behaviour).
People who suffer with anxiety and depression are more likely to make cognitive biases in their thinking. That means the “thoughts” are more likely to focus on the negative information, and exclude any positive information. For example, appraisals in anxiety disorders are more likely to have threat biases such as overestimating how likely bad things will happen and awfulising how bad these events could be. Examples of cognitive biases in depression are negative filtering such as only focusing on the one mistake I made in an overall great performance, or, overgeneralising that one mistake to mean I am hopeless at everything. This pattern of unhelpful thoughts leads to increased anxiety and depression that in turn influence unhelpful behaviours such as avoidance and withdrawal. Avoidance and withdrawal lead to more unhelpful thoughts, “I’m useless, I can’t even be around people” and more anxiety and depression and a self-perpetuating cycle of unhelpful thoughts, feelings, and behaviour continues.
These principles form the foundation on which CBT is based. Knowing the relationship between thoughts, feelings and behaviours, and that people with anxiety and depression have biased thoughts and unhelpful behaviours, means psychologists have a point of intervention to work on. We can work on helping people to overcome the negative bias in their thinking (cognitive therapy) and we can work on overcoming unhelpful behaviours such as avoidance and increase more helpful behaviours such as facing one’s fears, increasing pleasant activities, and improving interpersonal skills with skills development training (behavioural therapy). We will hear more about the different therapeutic techniques used in CBT later, but first, let’s understand how CBT developed and what therapies CBT refers to.
CBT has evolved through three key phases of development. The first phase was behavioural therapy that focused on the link between behavior and emotions. Pavlov (1927) was one of the earliest influencers on CBT with his work on classical conditioning that lead to the conclusion that emotional responses can become associated with or conditioned responses to specific events. This lead to the work of Wolpe (1958) who developed systematic desensitisation, a procedure still used today where a person is systematically exposed to their feared object whilst simultaneously completing a relaxation task until the fear response becomes inhibited. Another key behaviourist was Skinner (1974) whom recognised the importance of the environment on influencing behavior. His theory on operant conditioning proposed that behaviour could be changed by changing what came before the behaviour (antecedants) or what came after the behaviour (consequences).
The second phase of development bought the introduction of Cognitive Therapy which recognised the important influence of intrapsychic processes, such as meanings and interpretations that are made about events, on emotions and behaviours. Ellis (1962) developed Rational Emotive Therapy and Beck (1963) in his work Cognitive Therapy for Depression proposed a theory of how depression is contributed to by cognitive bias in processing whereby the person distorts reality in unhelpful and depressing ways. These distortions and biases arise from negative core beliefs about oneself, others, and the world and the negative core beliefs form a filter through which the world, self and others are viewed. Kind of like wearing “rose coloured glasses”, or perhaps in the case of depression, dark tinted glasses! CBT interventions for depression and anxiety focused on challenging these thought biases to improve mood. Similarly CBT interventions also involved extinguishing fears through facing fears whilst relaxing.
Whilst CBT was effective for many people, it was observed that challenging thoughts to think in more realistic ways wasn’t effective for everybody. This gave rise to a third wave of Cognitive Behavioural Therapies where the focus became on changing one’s relationship with their thoughts and emotions, rather than trying to change them per se. Hayes et al. (1999) developed Acceptance and Commitment Therapy or ACT whereby a person will observe their thoughts, feelings, and behaviours and engage with them fully with an attitude of acceptance. Through mindful experiencing of thoughts and emotions the person learns to live with and tolerate that which was once believed to be intolerable.
Gilbert (2014) developed Compassion-Focused Therapy which focuses on the person developing an attitude of loving kindness towards oneself. This aims to create more balance in self-talk about oneself, which is particularly helpful where people have negative self-talk such as “I’m not good enough”, “I’m worthless”, or “I’m unloveable”.
Dialetical Behaviour Therapy (DBT) was developed by Linehan (1993) to help people with destructive patterns of behavior. The principle of DBT is that problem behavior is a result of skill deficits and therefore focuses on increasing skills for emotion regulation and interpersonal effectiveness including learning the skill of mindfulness. DBT focuses on learning to tolerate distress, rather than trying to change the situation.
Finally mindfulness-based CBT (MCBT) was developed by Segal et al. (2002) and incorporates meditation techniques to focus on the present moment. MCBT encourages mindful awareness of thoughts and feelings, and encourages observing these with an open and non-judgmental mind. Again this technique focuses on learning to engage our thoughts and emotions fully without needing to change them.
Whilst CBT is an umbrealla term to encompass all of these different psychotherapies, there are a number of principles that they all have in common.
CBT is based on strong theoretical models such as cognitive models of disorders. These models provide understanding of disorders and inform us of choices for interventions. CBT is not freely talking about whatever you so wish or a collection of techniques applied willy nilly.
CBT focuses on current experiences of situations, thoughts, emotions and behaviours. It does not seek to understand unconscious motivations or origins of problems such as early childhood traumas.
CBT is a process of the therapist and client working together to come to a shared understanding of the problem. The therapist brings their skills and training to help interpret the client’s experience of their world. The therapist guides the client on a process of discovery rather than telling the patient what is wrong. The client has an active role in determining their goals, monitoring their thoughts and behaviours, practicing new skills, and reviewing their progress.
Compared to some psychotherapies that involve several sessions a week for several years, CBT is time-limited with most interventions being completed in 12 to 16 sessions. Sessions may commence weekly so that momentum can be built and change can be effected quicker, then when the client is feeling more confident to work independently between sessions, sessions may move to fortnightly and eventually monthly, allowing the client to practice their new skills independently.
CBT has a structured approach that is problem focused and goal-orientated. CBT begins with an assessment to identify the problems and maintaining factors, setting goals and targets for intervention, intervention, monitoring and evaluation of progress. Each session continues this process with a review of progress, ongoing assessment, identification of any problems that occurred throughout the week, revision of goals and intervention choices, new interventions and setting goals for homework task completion.
CBT focuses on teaching new skills to help clients think more rationally and make behavior choices that are more helpful. The therapist will set weekly homework that will involve practicing the new skills between sessions. Acquisition of skills is monitored weekly and the therapist helps the client to generalise their new skills to the real world. Next we will look at the specific techniques and skills taught in CBT.
So you want to know what you will be doing if your mental health therapist offers CBT? Below is a list of possible techniques your therapist may utilise when supporting you to overcome your problems:
An ongoing process in CBT is education on psychological theory to help you to understand how you experience your thoughts, feelings, and behaviours, how these are maintained, and how you can get better.
Your therapist may ask you to monitor your activity and mood throughout the week in order to examine patterns between behavior and emotions. This will also help identify behaviours that are in excess, such as watching tv, and behavioural deficits, such as minimal social or physical activity, and which activities are associated with better mood.
Once an activity monitor has been completed and areas for improvement have been identified, your therapist will encourage you to schedule in activities that will give you a sense of accomplishment or pleasure, to help improve your mood.
Sleep problems such as trouble falling to sleep, waking in the early hours of the morning, or sleeping too much are common issues in mental health. A therapist will work with you to help improve your sleep routine so that your mind is getting just the right amount of restorative sleep for well-being.
A very important cognitive therapy technique involves increasing awareness and insight in to your self-talk. To do this, your therapist will work with you to identify your inner thoughts that are connected to different emotional states, different situations, and different behaviours. You might be asked to keep a “thought record” between your sessions so you can work on your thoughts in session.
Cognitive distortions are thinking styles that are irrational, unhelpful and contain biases. We all have cognitive distortions, however, someone with anxiety or depression, will use these thinking styles more frequently. Once you have completed a thought record, you and your therapist will evaluate your thoughts for cognitive distortions and you will learn skills on how to challenge these distortions and think in more helpful and realistic ways.
Your therapist will help you to identify and acknowledge your strengths. These strengths can then be used to empower you to face new challenges.
A technique in Acceptance and Commitment Therapy is to explore and identify your values in life. These values are used to guide you to set goals in different areas of your life such as work, relationships, leisure, and community. A life lead by your values is believed to lead to a sense of fulfillment and wellbeing.
Mindfulness training is about learning to observe your thoughts and mind in the present moment with a sense of curiosity, openness, and non-judgement. This skill aims to change your relationship with your thoughts rather than to change your thoughts.
Part of DBT involves monitoring your emotions, understanding what triggers different affective states, and learning skills to help tolerate distressing emotions.
Unhelpful core beliefs and low self-esteem are worked on through encouraging self-acceptance and learning skills of self-compassion. This involves learning to acknowledge your personal suffering, defusing from self-judgement and responding to yourself with loving kindness and compassion.
CBT can include training in such skills as communication, assertiveness, conflict resolution, social skills, emotion regulation skills, and problem solving. Interpersonal skills can be modelled by the therapist and then practiced in the safety of the therapy room by doing role plays.
In CBT there is no other more powerful way to develop new ideas and alternative beliefs than obtaining new evidence from conducting behavioural experiments. A well-designed experiment can help to test out unhelpful assumptions and old beliefs, whilst developing new beliefs in the light of new evidence. An example of a behavioural experiment to test the belief that “people will laugh at me if I make a mistake” would be to set up an experiment whereby the patient or the therapist would intentionally make a mistake when ordering a coffee. Then, responses of others and outcomes are evaluated to come up with a new belief based on the new evidence that “people try to be helpful when a mistake is made”.
A behavioural technique when treating anxiety and fear involves developing a fear hierarchy which defines your least feared situation to your most feared situation. Then, your therapist supports you to face your fears, step by step in a process of graduated exposure, whilst using your new coping skills to help tolerate the anxiety associated with your fears. Fears are faced over and over until the feared situation no longer triggers a fear response. Once you have mastered one step, you are ready to face the next step. This technique is used to conquer fears such as heights, panic attacks, social anxiety, or driving a car again after an accident.
CBT is an evidenced based treatment for many psychological disorders. It has been found to be an effective treatment for anxiety, depression, chronic pain, eating disorders, substance use disorder, bipolar, insomnia, anger and aggression and more (Hoffman et al., 2012). Because of its extensive body of empirical evidence, CBT is an approved therapy under Medicare and is accepted world-wide as an evidenced based psychotherapy for adults, children, and young people.
Mental health practitioners are trained in CBT. This can include psychologists, psychiatrists, mental health social workers, speech therapists, occupational therapists, and GPs.
If you wish to consult a CBT Professionals mental health worker to commence a CBT program, please download our Referral Form here and take it to your GP to gain a referral.