I practice a variety of treatment modalities that I’ve learned through education, training and experience in the field over the last decade. I select specific interventions based on each client’s symptoms, personality, level of motivation and interest. However, once a therapeutic relationship (the most important component of successful therapy) has been established, I consider Cognitive Behavioral Therapy (CBT) to be one of the more effective modalities for change.
CBT is a research-based treatment approach for mood and anxiety disorders that combines both cognitive and behavioral methods. It has strong support in scientific literature as an effective treatment. CBT can elicit insight about the origin of our thought patterns, behavioral outcomes, and reflection upon their impact on our lives. It can also elicit insight on how we view ourselves, others and the world.
THE ORIGINS AND THEORY BEHIND COGNITIVE BEHAVIORAL THERAPY
In ancient times, in the absence of therapists and psychiatrists, philosophers acted as “physicians of the soul.” Thus, people turned to them for guidance. Stoicism, a philosophy stretching back to ancient Greece, is a source of meaningful wisdom that has inspired many concepts in Cognitive Behavioral Therapy. Epictetus, a first Century Stoic philosopher, wrote that “man is disturbed not by things, but by the views he takes of them.” 2000 years later, this became the central idea of cognitive therapy. The concept of thought as the basis for feeling is also now reflected in modern psychology. It is at the core of Cognitive Behavioral Therapy, which helps clients change the way they feel by changing the way they think. CBT draws heavily on mindfulness techniques and other ways of “thinking about thinking,” a perspective whose origin is in Eastern philosophy and adopted by modern western practices.
Logic, according to the Stoics, is the ability to determine truth from myth via reasoning. Despite what might in fact be true, we often see things as we imagine them to be, rather than how they really are. The truth becomes distorted by dysfunctional cognition resulting in destructive emotions and suffering. Cognitive Behavioral Therapy first asks the therapist and client to use logic in the therapeutic setting to find gaps between the client’s perceptions and reality. Logic dictates that rather than attempting to change nature we instead change our thoughts to align with it. We respond to our environment and the more we’re successful at thoughtful adaptation the less we’ll suffer.
GETTING TO OUR THOUGHTS
We can’t always change the circumstances or situations that life hands us, but we can change our thoughts about them. Thus, we can change how we feel about them. The central assertion of CBT is that situations are viewed through cognitive frameworks, or schemas, that lead to specific thoughts which over time become automatic. These thoughts are described by some cognitive therapists as Automatic Negative Thoughts, or “ANTs”. These are thought-traps and we often think them without knowing it.
The schemas are our “operating system.” The ANTs that come from them lead to feelings. Feelings can be pleasant or unpleasant; in the case of anxiety and mood disorders, therapy usually addresses unpleasant feelings of distress, fear, or hopelessness. Feelings are often difficult to change directly. However, Cognitive Behavioral Therapy focuses on changing the thoughts that lead to these feelings. Its premise is simple: by being mindful of our thoughts, we can change our feelings and, consequently, our actions. This helps us manage our lives more effectively, develop a positive outlook, and maintain constructive behavioral patterns.
Schemas are the structure of our thought patterns and beliefs are the content. We develop core beliefs about ourselves, others and the world based on early life experiences, usually originating in preadolescence. Our schemas are built around our core beliefs and reinforced as we age. By adjusting our thoughts, we directly influence our emotions and behaviors. This adjustment process is referred to as cognitive restructuring. Aaron Beck, the psychiatrist widely considered to be the father of cognitive therapy, believed that when a person’s thinking pattern is established certain cognitive errors or distortions develop and lead to depressogenic or dysfunctional assumptions.
TRY THIS
Think about a memory, good or bad. What do you notice? Most of us will experience an emotion, conveying a cause and effect relationship between our thoughts and feelings. Changing our thoughts or perception of events—rather than the events themselves—determines how we will feel and act. For example, if we experience anxiety and strongly believe that “everything will turn out badly today,” then these negative thoughts may influence us to focus only on the perceived negative things that may happen while blocking out or completely avoiding thoughts or actions that may disprove that negative belief system. Afterward, when nothing is perceived to go right in the day, we may feel even more anxious than before, the negative belief system is strengthened, and we are at risk of being trapped in a vicious, continuous cycle of negativity and anxiety.
MY APPROACH
My approach to uncovering core beliefs involves a three step process. First, we establish a strong therapeutic rapport. Then, we identify previous significant (or sometimes seemingly insignificant) life events. Finally, we explore their impact on us. This is a process I call the “Downward Arrow.” We usually begin by identifying a time in our lives that was impactful. With further exploration, we can discover specific events or patterns that we experienced. Still moving downward, we examine the impact they have had on us and the underlying belief system about ourselves that has developed. Lastly, we identify specific value-language by which we identify ourselves and through which many events in our lives are filtered. This is an authentic and sometimes emotional process invaluable not only in its utility for CBT but for personal insight.
In CBT, we identify our core beliefs and focusing on our thoughts that come from negative cognitive schemas. Thus, we employ new more realistic, updated and accurate value-thoughts that are positive. Our emotional and behavioral response changes commensurately. Through CBT, we learn that our perceptions directly influence our emotional responses to specific situations. Beliefs become thoughts, thoughts become feelings, feelings become actions and actions cause results. These results, or symptoms, are what bring us into therapy.
In other words, our thought process triggers self-defeating behaviors. These behaviors become barriers to wellness, negatively impact close relationships and lead to harmful consequences. Once we establish positive thoughts about ourselves and environment that inform healthier schemas, outdated negative thoughts become incongruent. Substituting dysfunctional thoughts with positive ones is more effective than just trying to eliminate bad ones. Unlike traditional “talking therapies,” CBT is a short-term, problem-focused form of behavioral treatment. It is usually brief (about 12 sessions, on average) and focuses on finding solutions to specific problems.
DOES COGNITIVE BEHAVIORAL THERAPY WORK?
Scientific research shows that CBT works—often better than medication alone. In a 2012 UK study of 469 people with treatment-resistant depression, those who received CBT plus medication were three times more likely to get at least a 50 percent improvement in their symptoms than those who received only antidepressants. In a Harvard University study that compared the short-and long-term effects of CBT to a prescription sleeping pill for 63 people with insomnia, CBT helped participants fall asleep faster and sleep with fewer interruptions. And they were still sleeping better a year later. CBT can even ameliorate chronic symptoms (such as chronic pain and tinnitus) by improving coping skills.
Brain scans reveal that CBT can change the brain, a process known as neurogenesis. In a University of Pittsburgh study, functional MRI images showed that activity in the brain’s subgenual cingulate cortex (a region associated with mood regulation) was low in people with depression but increased after 12 weeks of CBT. Other research has uncovered beneficial increases in brain activity after CBT for people with post-traumatic stress disorder, obsessive-compulsive disorder and panic disorder.
LIMITATIONS OF COGNITIVE BEHAVIORAL THERAPY
People who experience vague feelings of unhappiness, without clearly defined symptoms or issues, may have limited success with cognitive behavioral therapy. CBT may not be effective for clients with personality disorders or who have low levels of motivation. Additionally, while individuals with long-term health issues can use CBT to better cope with their condition, the physical symptoms of these conditions cannot be cured with CBT. Cognitive Behavioral Therapy can help a person in treatment develop more positive thought patterns and behaviors. However, without willingness for self-discovery, they may not gain insights into the psychological and emotional underpinnings of their behavior.
FINAL THOUGHTS
Cognitive Behavioral Therapy is not a quick fix. Therapists need to demonstrate considerable expertise in the approach. As well, clients will benefit most when they cooperate fully with the treatment program. CBT therapists aim to help build the set of skills that can be developed, practiced and applied outside therapy sessions. This aspect makes CBT different from other therapies. Daily practice of exercises and applying what has been learned is a critical component for success. Clients spend one hour a week in therapy. It is during the remaining hours and days of the week that require dedicated attention to new thinking skills, awareness of negative thought patterns and practice challenging them. This includes reading, keeping thought journals, measuring degrees of emotional responses, and identifying activating events that cause distress. It also includes mood tracking and documenting behavioral results.
I have had numerous clients who after a few sessions identify their core belief, its etiology and the mechanics of CBT, which is meaningful, only to return for subsequent sessions sometimes indicating not experiencing change. This usually happens when work outside of the therapy session has been discounted. In other words, the behavioral aspect of CBT has been ignored. However, when practiced on a consistent basis with concurrent therapy sessions, Cognitive Behavioral Therapy can be effective.