Understanding Cognitive Behavioural Therapy
CBT is an active, collaborative, solution-focussed form of therapy combining techniques that help us to confront and correct biases and problems in the ways we think and feel; leading us to independently pursue a more fulfilling and successful life.
The theory and process of CBT
The aim of Cognitive Behavioural Therapy is to develop more helpful thoughts and actions that can guide us towards happier and more fulfilling lives. CBT is a short-term therapy: it can last anywhere between 5 and 30 sessions over a period of 1 to 18 months, depending on the particular concerns and needs of the client.
The therapist works actively and collaboratively with them, helping them to identify maladaptive patterns of thoughts and behaviours through logic and experiment, and arming them with the skills and techniques to replace them.
In this way, the client gradually learns to become their own therapist, so that when they face difficult situations in the future once therapy has ended, they are able successfully to tackle them alone.
This is thought to be one of the reasons that CBT yields much lower relapse rates for a variety of concerns when compared to medication alone, and can be contrasted with traditional Freudian psychoanalysis, in which therapy can last for years and even decades. Where the Freudian assumption is that the therapist holds the ‘key’ to helping the client, CBT proposes that this power lies within the client themselves: the therapist’s role is merely to help them discover this.
Although CBT therapists do not disregard entirely the causal mechanisms behind the client’s problems: the focus is very much on the here-and-now, on what is maintaining the issue: we cannot change our past, but we can change the way we deal with things in the present, and this is the best chance we have for shaping a more positive future.
So how does CBT actually tackle our cognitions and behaviours?
The theoretical model behind CBT holds that we all have a ‘cognitive triad’, which consists of our habitual thoughts and beliefs about ourselves, others and the world. This influences how we interpret and evaluate what happens to us (cognition), how we feel about it (emotion), and how we respond (behaviour).
Sometimes our thoughts within this triad can be distorted, biased, or just plain erroneous. For example, common ‘cognitive biases’ in the depressed include:
- Dichotomous thinking: Viewing everything as a binary (either entirely good, or entirely bad) with even the smallest problem or flaw rendering a situation hopeless
- Overgeneralization: Extrapolating from one negative event to view everything as negative
- Magnification or minimization: Inflating the negative details and ignoring or minimizing the positive details
- Confirmation bias: Searching for or interpreting information in a way that confirms one’s preconceptions
- Pessimism bias: The tendency to overestimate the likelihood of negative events occurring.
When the thoughts within our cognitive triad (and the more immediate ‘automatic thoughts’) are problematic, this can be upsetting (i.e. affect the way we feel) and lead to difficulties in how we live our lives and interact with others (i.e. affect the way we behave).
The role of the CBT therapist is therefore to help you to become more aware of your cognitions and how they may not be helpful, and develop the skills needed to modify them when they are distorted or not useful. Eventually, this becomes habitual and leads us towards a more realistic way of viewing the world without conscious effort. This is known as ‘cognitive restructuring’.
Habitual behaviours maintain the problem
Just as the way we think can maintain our problems, so can the way we behave. Commonly this is due to avoidance (either of actual situations or internal experiences such as feelings and memories). For example, if someone is struggling with social anxiety, they may shun situations in which they have to interact with new people, or a lot of people at once.
They may turn down social engagements, or stop going to work. This cuts them off from the possibility of positive experience in these situations (thus reducing their satisfaction and motivation), and they may be left home alone ruminating on their unhelpful thoughts, which can make them worse. It also takes away any opportunity to disprove the biases in their cognitive triad.
If you turn down social engagements because of thoughts like “I will make a fool of myself”, “Everyone will laugh at me” or “I will have nothing interesting to say”, there is no way to find out if these thoughts are true. CBT often sets ‘behavioural experiments’ for the client to engage in between therapy sessions (increasing in difficulty as therapy progresses and the client gains confidence).
In this situation for example the therapist may take the client through a series of relaxation techniques to combat the physical feelings of tension and nervousness that they feel when in social settings. They may then be encouraged to talk to someone new within the week, and write down their thoughts and feelings about this, what happened, and whether these elements matched. Often, the person will discover that their negative thoughts are not as realistic as they previously thought. It is this realisation which is an important foundation for change.
A very well researched subject
CBT is one of the most well researched forms of psychotherapy: there are over 400 published studies on cognitive behavioural interventions and NICE–the National Institute for Health and Clinical Excellence–recommends it in the UK as the treatment of choice for a wide variety of concerns.
In 2005, Aaron Beck (‘the Father of CBT’) and his team of researchers at the Beck Institute for Cognitive Therapy analysed the results of 16 meta-analyses of CBT, covering almost 10,000 participants in 332 studies. They found that CBT was strongly effective for depression, generalised anxiety, panic and agoraphobia, social phobia, post-traumatic stress, and childhood depression and anxiety.
It was also found to be effective for relationship problems, anger, childhood somatic disorders, eating disorders, schizophrenia and chronic pain. Most interestingly perhaps, they found that CBT is superior to antidepressants in the treatment of adult depression.