 | WHAT
IS CBT?
Cognitive behaviour therapy is a practical and goal
orientated approach toward solving emotional and behavioural problems. CBT understands
and aims to treat our emotional and behavioural problems by placing a strong emphasis
on our ways of thinking in today's world as oppose to what has happened in the
past. The underlying philosophy of CBT revolves around the idea that our emotional
state and behavioural reactions are a product of our ways of thinking about our
respective situations. How we think (the rules we use) and what we think (what
we tells ourselves about our respective situations) determines how we are affected
by the events (ordinary and extra-ordinary) of everyday life.
Cognitive-behaviour
therapy consists of a combination of techniques and theoretical ideas from two
initially separate but now often co-jointly used schools of thought:
- Cognitive
therapy involves the use of cognitive disputation of dysfunctional/irrational
beliefs that are often seen as central to our disturbance.
- Behavioural
techniques are regularly used and utilized as a means of reducing emotional distress,
altering dysfunctional behaviour and overcoming certain challenges.
It
is therefore the underlying assumption of CBT that if we are able to change the
manner in which we think about an event, then we will most likely be able to feel
differently about it and alter the way we react to it. However, the mechanisms
of change are not quite as linear or simplistic as many seem to think and behavioural
changes may often also lead to changes in our thinking. For example, once we have
done something that we have been afraid of doing, we often tend to no longer think
of it as dangerous or difficult.
The cognitive model suggests that our emotional
states are strongly influenced by our cognitions or thinking patterns. As a result,
changing the way that we feel is often readily achievable by making changes in
our thinking. The best way to overcome emotional distress that is seen as secondary
to irrational thinking is to change the irrational thinking itself. This does
not suggest that it is easy to change these beliefs. It often requires a great
deal of practice and perseverance.
IS
THERE A CONCEPTUAL SCHEMA THAT EXPLAINS THE THEORY?
The role
of cognition or our ways of thinking can be summarised, in a simplified manner,
as follows:
WHAT
ARE IRRATIONAL OR DYSFUNCTIONAL BELIEFS?
Cognitive therapy
is aimed at identifying those thoughts, attitudes and assumptions that create,
exacerbate or maintain intense, unnecessary emotions such as fear, anxiety, intense
anger, excessive shyness, and depression. Some of these cognitions or thinking
patterns may be very automatic and conscious whilst others may be a little below
conscious awareness. Once elicited and identified, these thoughts, assumptions
and attitudes are assessed in a scientific manner with regards to the following
principles:
- Whether they follow logical reasoning
- Whether
or not they are based on any objective evidence
- Whether they are helpful
or self-defeating
A variety of different types of irrational ways
of thinking exist. Once identified these thoughts, attitudes and assumptions are
disputed or challenged and ultimately replaced by healthier, more evidence based,
logical thinking patterns.
Central to, and underlying most emotional disturbance
is what Albert Ellis (Ellis & Harper, 1961) has referred to as evaluative
beliefs, also known as irrational beliefs. They tend to fall into one of four
categories according to the rational emotive behaviour therapy of Ellis:
-
Demands reflect unrealistic and absolute expectations of events or individuals,
they are recognised by words such as 'must, ought, should and need'. A typical
thought associated with performance anxiety may be, "I must do well in that
test and come at least in the top three in my class".
- Awfulizing
is a way of exaggerating the negative consequences of situations to an extreme
degree, so that an unfortunate event becomes a terrible thing. "It would
really be the end of my studies and my academic career if I don't achieve the
highest marks in my class, it would be terrible".
- Low frustration
tolerance (LFT) stems from demands for ease and comfort, and reflects an intolerance
of discomfort. "I would not be able to stand failing that test".
- Global
evaluation of human worth, either of self or others, implies that human beings
can be rated, and that some people can be worthless (including yourself) or at
least less worthy than others. "I would really be a failure and a worthless
idiot if I were to fail this test".
HOW
DOES CBT TYPICALLY WORK?
The psychotherapeutic process would
start with a general assessment of the nature and extent of the problem that one
is experiencing. This would include an assessment about current symptoms and general
background. This is done in order to establish the nature of the problem experienced
and is orientated toward the making of a diagnosis. This may take one to two appointments.
The
diagnosis and treatment options available are then discussed with the client.
This may include referral for medication, depending on the nature and severity
of the problem. At this point an estimate of the duration of psychotherapy can
be made. A treatment plan is generally discussed with clients before embarking
with the treatment process.
In most instances the client is educated on
the nature of his problem (e.g. In the case of panic disorder, a client would
be educated about the typical symptoms associated with panic disorder and the
neurological and physiological reasons for the symptoms).
From this point onward,
therapy sessions tend to follow a pattern. Therapeutic homework is typically given
to clients between sessions. A session would typically start with a review of
the past week. Thereafter the homework would be reviewed. This would be followed
by a discussion of the next phase of treatment (e.g. in the case of panic disorder
reviewing the fears that the client is experiencing in association with their
symptoms, such as " I feel I will have a heart attack (and die)!") This
would entail helping the client to understand the reasons for their symptoms and
helping them understand the irrational cognitions or thoughts that create, exacerbate
or maintain the problem. Cognitive disputation is then done with the aim of helping
clients change their unhelpful thinking patterns.
Homework exercises focus
on assisting individuals practice the skills learnt during therapy sessions within
the real world. These exercises tend to be aimed at practicing new healthier ways
of thinking and they often also entail behavioural assignments that are aimed
at hypothesis testing and other forms or symptom reduction. A client with panic
disorder may stop travelling to the local shopping centre due to fears of experiencing
a panic attack. This may be in reaction to having experienced one there previously.
Eventually they would be encouraged to return, once they are well prepared and
have a thorough understanding of their condition and how to manage it. Individuals
suffering from depression may be required to increase their participation in enjoyable
activities and work hard at changing depressogenic or depression-causing beliefs.
IS IT NOT NECESSARY TO UNCOVER
THE PAST IN ORDER TO REALLY UNDERSTAND PEOPLE'S PROBLEMS?
The
misconception exist amongst some, that CBT denies the relevance of the past. CBT
does recognise that we are strongly influenced by experiences throughout our life
and of course also early (childhood) experiences. How we think about life (our
life philosophy) is strongly influenced by earlier experiences. CBT suggests that
the influence of the past is only problematic because it operates in the present
in the form of beliefs that we carry with us in today's world. In CBT what happened
a second ago, with regards to our thinking, is just as important as what happened
to us 30 years ago. The past is thus seen as exerting its influence in the "here
and now" by the way in which our current day thinking is affected by it.
We cannot change the past, but we can change the way we let it influence us in
today's world, by addressing our thinking in the "here and now".
SHOULD
ONE THEN THINK OBJECTIVELY ABOUT EVERYTHING AND THEN NEVER EXPERIENCE NEGATIVE
EMOTIONS?
CBT recognises that emotion is part of every aspect
of our functioning. When emotion becomes so intense (rage, depression, jealousy)
then it affects our ability to function effectively. These intense emotions, and
the self-defeating behavioural responses that often accompany it are seen as the
result of a deterioration in the objectivity of our thinking. We start insisting
that others must adhere to the rules we make, we start believing that we cannot
tolerate being inconvenienced, we condemn others for there actions and tell ourselves
we are in the worst possible circumstances ever and the world might just end soon
(which of course is possible but not yet probable) and become generally intolerable
of our lives and its challenges. CBT helps individuals to restore a balance by
teaching ways to think more realistically about day-to-day events (driving in
peak hour traffic) and major events (chronic illness, traumatic events). One of
the greatest problems with the word emotion is that it is often used but seldom
defined. When people (and psychologists) talk about anger or annoyance, what do
they mean? When we use the word depressed or sad, what are we talking about. How
do we define the difference between concern and anxiety or embarrassment and shame?
Because of its scientific orientation, CBT practitioners try to be specific about
the language that we use. A strong emphasis is made between healthy negative emotions
and unhealthy negative emotions. The goal of CBT is not to have everyone feeling
positive all of the time - that would be unhealthy. Healthy negative emotion would
never be treated, but rather responded to with support and empathy. It is the
unhealthy emotion that CBT tries to help individuals with. The goal with unhealthy
emotions is often to help clients change them to healthier negative emotional
and behavioural reactions, but not necessarily positive ones. Irrational ways
of thinking tend to lead toward unhealthy negative emotions and rational thoughts
tend to underlie healthier emotional and behavioural reactions.
WHEN
A CBT THERAPIST HAS TREATED ME WILL I NEVER EXPERIENCE ANXIETY, ANGER OR DEPRESSION
AGAIN?
We all experience a whole range of emotions from happiness
to depression. It is however about the intensity of our emotional experience.
Intense anxiety can impede your ability to perform well in an exam; rage can lead
to you physically attacking someone who accidentally cut in front of you in traffic.
We would tend to focus on whether or not your emotional reaction is helpful or
whether or not it tends to lead to destructive behaviour and intense emotion?
Clients who are successfully treated with CBT may require booster sessions in
the future.
WHY
CONSIDER COGNITIVE-BEHAVIOURAL PSYCHOTHERAPY?
CBT is
a well-researched, outcome-orientated approach toward the treatment of emotional
and behavioural problems. Scientific studies on the treatment of a variety of
psychiatric conditions have been done. Some of the better-known conditions are
anxiety disorders (panic attacks, OCD, PTSD, specific phobias, social anxiety
disorder), depression, eating disorders, impulse control disorders, behavioural
problems and anger.
A search on research articles published on treatment
through CBT, shows more than 8000 articles being published. Research that meets
rigorous research methodology controls, on the outcome of CBT treatment is extensive.
Growing evidence from multi-centre research projects that measure the effectiveness
of treatment in different countries and cultures is also available.
There is
also a fast growing body of research that is orientated toward understanding the
neurological changes associated with CBT treatments for specific disorders. Modern
technology that allows us to measure brain metabolism, has shown the effects of
CBT on the brains of people with depression. We know now that a combination of
CBT and medication for depression is often the most helpful way of treating depression
but we also know that CBT and medication work on different parts of the brain.
There is also a significant amount of research that has investigated the pre vs.
post-treatment changes in brain metabolism associated with CBT for anxiety disorders
such as phobias, PTSD and OCD.
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