A Guide to Cognitive-Behavioral Therapy
Introduction to Cognitive-Behavioral Therapy (CBT)
Cognitive therapy emerged in the 1960s, leading to a large number of models that emphasize cognitive and behavioral changes. All cognitive-behavioral therapies share the following core concepts:
- People’s cognitive activity affect their behavior.
- This cognitive activity may be monitored and changed.
- Change in behavior results from change in cognitive activity.
Keith S. Dobson, PhD, and his colleagues point out that there are three major streams of cognitive-behavioral therapies, including:
- Coping skills therapies
- Problem-solving therapies
- Cognitive restructuring methods
These different classes of therapy orient themselves towards varying degrees of cognitive and behavioral changes.
This article outlines the key concepts in two major streams in contemporary cognitive-behavior therapy, Rational Emotive Behavior Therapy (REBT) and Cognitive Therapy (CT). It discusses CBT's main principles and techniques with video demonstrations of CBT techniques being used in therapy sessions.
How much do you know about CBT?
Complete the poll below and find out.
What do you know about CBT, Aaron Beck, and Albert Ellis?
Conversation with Albert Ellis - Founder of Rational Emotive Behavior Therapy (REBT)
Rational Emotive Behavior Therapy (REBT)
REBT was developed by Albert Ellis over 50 years ago. The model proposes that human thinking and emotions are considerably related. Ellis posits the ABC model where consequences (C) are determined by people’s belief system (B) about an activating event or experience (A).
In his book, New Directions for Rational Emotive Behavior Therapy: Overcoming Destructive Beliefs, Feelings, and Behaviors, Ellis uses the term "awfulizing" where people view some events as awful and terrible which leads to more frustrating and painful feelings. This is so because when people "awfulize" they see the situation as completely bad and in no way beneficial.
On the other hand, the idea of “rationality” is a core concept in REBT. Rationality suggests what is true, logical, and empowers people to achieve their goals. In contrast, “irrationality” is what is untrue, irrational and hinders people from achieving their goals.
Dimensions of psychological health in REBT involve concepts such as:
- valuing oneself (self-interest)
- caring for others and contributing to the world which enhances happiness
- having meaning goals and direction
- experiencing high frustration tolerance
- exercising awareness of oneself and others
- taking responsibility for one's emotional difficulty
In a nutshell, REBT proposes that psychological disturbances result from people's unqualified evaluations of events in their lives that take the form of “musts”, “shoulds”, “have to's” and “oughts.” However, REBT posits that people have the capacity to change their irrational thinking and in so doing significantly change their disturbances.
Conversation with Aaron Beck - Founder of Cognitive Therapy (CT)
Cognitive Therapy (CT)
Cognitive Therapy was formulated by Aaron Beck, a psychiatrist. Like Albert Ellis, he questioned psychoanalytic formulations originating from the Freudian orientation. Cognitive Therapy emphasizes the way in which distorted thinking and unrealistic cognitive assessment of events affect people.
The model proposes that there is a strong relationship between affect and cognition. In her book, Cognitive Behavior Therapy: Basics and Beyond, Judith Beck, PhD, points out that underlying this relationship is “schemata” which is the core belief of the individual.
Maladjusted individuals possess negative schemata which lead to distortion of reality and psychological disorders. However, people who are well-adjusted hold positive schemata that lead to realistic appraisal of events. Beck identifies a number of common cognitive errors in the following categories that must be recognized and changed.
- All or nothing thinking: viewing situations on one extreme or another rather than on a continuum.
- Over-generalization: drawing sweeping conclusions with no evidence to justify them.
- Discounting the positives: telling themselves that the good things that happen to them do not count.
- Jumping to conclusions: drawing hasten conclusions that are not warranted.
- Magnifying or minimizing situations: emphasizing the the negatives and discounting the positives in situations.
- Making “should” statements: having well defined ideas of how people should behave.
- Mind reading: believing they know what others are thinking.
The goal of cognitive therapy is to replace patient’s distorted assessment of the events in their lives with realistic and adaptive appraisals. This leads to solutions of their current psychological distress.
Main Principles of Cognitive-Behavioral Therapy
Cognitive-Behavioral Therapy is a psychological treatment that focuses on the interaction between how people think, feel, and behave. It combines cognitive therapy and behavior therapy to help patients charge their self-defeating patterns of thinking and behavior that could cause difficulties.
Various approaches to CBT suggest that it is not the events that upset people but the meaning that is given to them.
- CBT focuses on the here and now. It addresses the symptoms that patients struggle with right now rather the cause of the problem.
- The use of homework is a central feature of CBT. This is between session practice. Patients need to practice the new skills that they are learning and apply them in their lives daily. The aim is to make the CBT skills became a part of the patient's daily routine. The more the skill is used the easier it gets.
- CBT is based on a structured education model. The treatment sessions include setting agenda for session, reviewing homework, learning new skills, and developing homework assignment for the next session.
- There is collaborative effort between the patient and therapist. This is an important focus of CBT. A sound therapeutic alliance between the patient and therapist increases understanding of presenting symptoms and how to manage them. Patients are encouraged to participate in and out of sessions to see improvements.
- CBT is time-limited and is usually 10-20 sessions in duration. Patients are required to learn new skills to help them manage their problems and see positive changes in their lives. In a sense, patients learn to become their own therapists.
Cognitive-Behavioral Therapy Interventions
CBT is used to treat many mental and psychological disturbances, and evidence supports its effectiveness in treating such disorders as:
- anxiety disorder
- panic attack
- depression and dysthimia
- personality disorders
- eating disorders
- obsessive compulsive disorders (OCD)
- post-traumatic stress disorders (PTSD)
- psychotic disorders
As its name suggests, CBT incorporates a wide variety of cognitive and behavioral techniques to treat patients. The sessions are structured and include setting agenda, prioritizing items for the session and reviewing homework given in previous session. Some cognitive and behavioral strategies used include:
- Modifying beliefs using Socratic questioning. This involves identifying and changing inaccurate and dysfunctional thoughts that contribute to the patient's distress. This leads to patient learning to find more self-enhancing ways to view their situations
- Behavioral activation. Since there is a relationship between mood and behavior, the aim is to help patients to engage in more enjoyable activities. The therapist helps patients schedule pleasurable experiences of which they keep a record and note how they felt.
- Relaxation techniques are designed to reduce tension stress and anxiety. There are three major types of relaxation techniques which use verbal imagery, breathing exercises and progressive muscle relaxation.
- Homework is an important aspect of CBT. It enables patients' collaboration in their treatment. They practice skills taught in therapy in real life situations and see progress on their own. The Thought Log is an important tool used for homework assignments in CBT.
The two videos below illustrate the use of CBT techniques in treating patients with symptoms of depression and social anxiety.
CBT: First Session with a Client with Symptoms of Depression
In this first session, the CBT therapist orients the patient to CBT which includes discussing the theory underlying the approach. The therapist uses the patient's examples to explain the cognitive-behavioral model, and help the patient to see how the model works.
The video above demonstrates a portion of the first session using CBT with Lucy, a patient experiencing symptoms of depression. The therapist explains Lucy's problems in terms of cognitive and behavioral symptoms. For example, the cognitive characteristics of Lucy's depressive symptoms include having negative thoughts about herself, such as:
- It's pointless
- I don't deserve to be here
- I am unworthy.
The patient's thoughts lead to emotions such as sadness, anger, frustration and embarrassment. These in turn result in physical sensations such as being drained of energy and sleeping problems. These behavioral characteristics are ways in which Lucy's body tells her that she is depressed.
The therapist uses effective questioning techniques to help Lucy see how her negative thoughts contribute to her current psychological distress.
CBT: Using Downward Arrow with Symptoms of Social Anxiety Disorder
CBT Interventions: Downward Arrows and Thought Challenging Techniques
The downward arrow technique is used to help the patient identify, understand and contradict self-defeating beliefs. CBT therapists ask patients the meanings of a series of related negative thoughts with the goal of uncovering intermediate and core beliefs.
Core beliefs are central ideas about ourselves and reflect our views about the world, people and the future. They are usually formed in childhood and are reinforced over time by our experiences. They are global so they cut across all the areas of life. Negative core beliefs could include, "I am unlovable" and "I am incompetent."
Core beliefs give rise to intermediate beliefs which are assumptions, attitudes, and absolute rules that people follow in situations of their life. These rules guide automatic thoughts and influence behaviors.
In the video above, the patient, Hannah, is experiencing symptoms of social anxiety disorder. She worries that she will do something stupid, spends a lot of time on her own, and feels that she is not worth being friends with.
The therapist uses downward arrow techniques to uncover her underlying dysfunctional thoughts. She challenges Hannah's inaccurate and unhelpful thoughts and beliefs through Socratic questioning. This is asking a series of open-ended questions that is to guide Hannah to discover the dysfunctional thoughts, feelings, and behaviors associated with her social anxiety.
Central to the cognitive-behavioral approach is the concept that peoples' beliefs are the basis of emotional problems such as depression and anxiety. CBT also maintains that people have control over their thoughts and actions.
Thoughts are readily available and are amenable to change. As such, CBT therapists teach the model to patients to help them understand their cognitive difficulties and how to change them. This empowers patients as they learn to identify, challenge, and change their self-defeating thoughts.
AnxietyBC (n.d.). What is Cognitive-Behavioral Therapy? Retrieved from AnxietyBC, September 9, 2016.
Beck J. S. (2001). Cognitive Behavior Therapy: Basics and Beyond (2nd ed,). New York, NY: Guilford Press.
Cully, J. A. & Teten, A. L. (2008). A Therapist Guide to Brief Cognitive-Behavioral Therapy. Retrieved from Mental Illness Research Education and Clinical Center (MIRECC), September 9, 2016.
Dobson, K. S (ed.) (2001). Handbook of Cognitive-Behavioral Therapies (2nd ed) . New York, NY: Guilford Press.
Ellis, A. (2001). Rational Emotive Behavior Therapy: Overcoming Destructive Beliefs, Feelings, and Behaviors, Amherst, NY: Prometheus Books.