What are the fundamentals of Cognitive Behavioral Therapy? - Chapter 1

  Chapter 

In the 1960s, Aaron T. Beck, MD, a practicing psychoanalyst, wanted to empirically demonstrate psychoanalytic theories so that they would receive more respect in the scientific community. He identified that distorted, negative cognition was a defining feature of depression and created Cognitive Behavioral Therapy as a short-term treatment that would target those negative cognitions.

What is CBT?

Cognitive Behavioral Therapy (CBT) is a structured, short-term, present-oriented psychotherapy used for depression. It targets dysfunctional thinking and behavior in order to solve current problems in the patient’s coping. The therapy has seen countless adaptations and use with a number of different psychological disorders beyond depression. In all forms of CBT, treatment is based on the understanding and conceptualization of individual patients as the therapist seeks different ways to encourage cognitive change and bring about enduring emotional and behavioral change.

What are the different types of CBT?

Variations on CBT tend to emphasize different elements of the treatment. These variations include:

  • Rational emotional behavior therapy.

  • Dialectical behavior therapy.

  • Problem-solving therapy.

  • Acceptance and commitment therapy.

  • Exposure therapy.

  • Cognitive processing therapy.

  • Cognitive behavioral analysis system of psychotherapy.

  • Behavioral activation.

  • Cognitive behavior modification.

  • And others.

CBT often uses techniques from these other therapies, so they are all interconnected. CBT has also been adapted for patients in all levels of socioeconomic status and many different cultures. It can be used in group, couple and family therapy, as well as in child therapy. It can be shortened for patients (like those with schizophrenia) who cannot tolerate a full session.

What is the Cognitive Model?

The Cognitive Model is the theory that underlies Cognitive Behavioral therapy. According to this model, dysfunctional thinking disrupts a patient’s mood and behavior and causes psychological disturbances. To recover from psychological disturbance, then, involves developing a more realistic and adaptive way of reflecting on one’s thought processes, and frequently questioning the validity of automatic negative thoughts. Such automatic negative thoughts can lead to damaging emotions like sadness and damaging behaviors like isolating oneself.

Does treatment have a lasting effect?

In order to treat patients in a meaningful and lasting way, CBT therapists will focus on a deeper level of cognition: a patient’s fundamental beliefs about themselves, the world, and other people. If a person has an underlying belief that they are incompetent, this may manifest in them frequently underestimating their abilities and feeling powerless. Combating this belief would involve focusing on specific situations in which it is proven false, and would allow one to see that having difficulty with certain tasks does not make one universally incompetent.

What sort of support is there for CBT?

There is overwhelming support (more than 500 outcome studies) for the efficacy of CBT as a therapy for depression and other psychological disorders. Several researchers have found that there are neurobiological changes associated with CBT.

How did CBT come into being?

One of the main concepts of psychoanalysis is that depression is hostility turned inwards. After some research, Beck found instead that depressed people have more feelings of defectiveness, deprivation, and loss. He observed patients having two streams of thoughts – automatic negative thoughts and evaluative thoughts closely tied to emotions. When Beck helped patients identify, evaluate, and respond to these unrealistic thoughts, they rapidly improved. Beck taught his residents to use the treatment, and eventually worked together with A. John Rush on an outcome trial in 1977. This trial established that CBT was at least as effective as a common antidepressant used at the time.

CBT helps patients identify and solve problems, activates their behaviors, and helps curb depressed thinking and beliefs. Patients with anxiety not only need to learn to better assess risks, they also need to decrease avoidance and confront scary situations.

What are the principles of CBT Treatment?

While CBT must be tailored to the individual patients, there are certain underlying principles that persist through all effective CBT treatments.

CBT is based on the constantly changing formulation of a patient’s problems and the conceptualization of that patient in cognitive terms

    Current thinking is identified to see where feelings of sadness originate. Problematic behavior is identified, as well as any precipitating factors that may have influenced perceptions at the beginning of the depression. A hypothesis is made about how developmental events may have caused enduring patterns of interpretation to occur and to predispose the patient to depression. Once the patient is taught how to recognize destructive thoughts, they are taught to formulate more adaptive cognitions

    CBT works on a firm therapeutic alliance

      Therapists working with CBT must form an alliance with their patients, sharing a trusting relationship and regarding the patient with care and warmth.

      CBT requires active participation and collaboration

      CBT encourages the patient to see the therapy as teamwork – the therapist and patient decide together what sort of work needs to be done, and how to do it.

      CBT is goal-oriented and problem-focused

        CBT involves working towards specific goals that are decided upon in the initial sessions. Thoughts that interfere with that goal can be more easily identified and interrupted.

        CBT begins by emphasizing the present

          Whereas some therapies emphasize the origin of issues (the past), CBT is all about the present, regardless of the diagnosis. CBT only looks at the past in order to provide a context to explain the childhood roots of dysfunctional thinking, or because the patient expresses a strong desire to focus on the past.

          CBT involves education and emphasizes relapse prevention

            Educating the client is an essential element of CBT. Not only does the therapist explain how automatic negative thoughts impact behavior, but they also help the client set goals, identify and evaluate thoughts, and plan behavioral change. Therapy notes are taken home so that the client may benefit longer from their treatment.

            CBT aims to be time-limited

              Depression and anxiety disorders tend to receive a treatment of six to 14 sessions, with the goal of relieving symptoms, training positive coping methods, and helping patients solve their most pressing problems. Some patients are easily treated in a short amount of time, though others with more rigid beliefs may need a couple of years of attention.

              CBT sessions are structured

                A session of CBT follows a certain structure designed to maximize the efficiency and effectiveness of the treatment. This involves an introduction (a mood check, a weekly review, etc.), a middle (homework review, problem discussion, etc.), and a conclusion (homework assignment, feedback).

                CBT teaches patients to identify, evaluate, and respond to dysfunctional thoughts

                Therapists help patients identify the key cognitions that lead to their anxiety and to adopt more realistic, adaptive cognitions that will lead them to feel better and tackle issues more effectively.

                  CBT uses different techniques to change thinking, mood, and behavior

                  Strategies like Socratic questioning and guided discovery are only some among many techniques used in CBT. Problem-solving and behavioral techniques are also essential. Psychodynamic techniques can help as well. It is a case-by-case decision.

                    How does a CBT session generally play out?

                    It begins with reaffirming the client-therapist relationship. The therapists checks on the patient’s mood, symptoms, and experiences from the week. Together, they decide which problems will be dealt with. Homework and the action-plan are reviewed. As a specific problem is discussed, the cognitive processes involved in the problem are brought up and can be picked apart. A strategy for solving the problem is then collaborated upon. New homework is assigned.

                    How to become a CBT Therapist?

                    CBT seems, from an outsider’s perspective, to be very simple. However, the CBT therapist must be able to conceptualize the case while building up a relationship with their client, as well as socializing and educating them. They must be able to identify problems, collect data, test hypotheses, and summarize. An inexperienced CBT therapist often has trouble doing all of these things at once – this is where the highly-structured format comes into play.

                    Developing expertise in CBT is a three-stage process. Stage 1 involves learning the basic skills of conceptualizing a case in cognitive terms based on data collected in the initial evaluation and in the sessions that follow. Structure and common sense help the therapist then identify problems and dysfunctional thoughts during the sessions. Stage 2 involves becoming more proficient at integrating the conceptualization with the tools and techniques available to any CBT therapist. Once this becomes easier, the therapist becomes more skilled in identifying critical treatment goals and conceptualizations. In Stage 3, new data is able to be automatically integrated into the conceptualization of the case – hypotheses are easier to formulate, and tools are more easily accessible.

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