What is CBT?
Dr Fiona Kennedy
Cognitive Behaviour Therapy is the intervention of choice for many conditions, such as depression, anxiety disorders (including post traumatic stress disorder and obsessional compulsive disorder), eating disorders (bulimia, anorexia, binge eating, obesity). In the UK, National Institute of Clinical Excellence (NICE) guidelines recommend CBT as the treatment of choice for many of these conditions, based on all available scientific evidence. CBT involves collaboration with the therapist to learn about patterns in thought, feelings and behaviour which maintain problems. Once we have agreed about these patterns, you will learn to apply basic strategies and principles of behaviour change that (a) are supported by scientific research and (b) can be applied flexibly and creatively to particular people in particular situations.
There are specific technical procedures used in cognitive behaviour therapy. However, contrary to the impression people sometimes have, CBT is more than a collection of techniques. Not all of them are certain to be used in your treatment, and others may be added. But this list will give you an idea of what to expect.
Cognitive modification (automatic thoughts)
“Automatic thoughts” are thoughts that come to mind involuntarily and effortlessly. You may not even notice them unless you make a point of looking for them. They may or may not have an appreciable effect on your feelings, moods or behaviour. When they do, their effects may be beneficial, harmful or neutral.
Most of our thoughts are automatic — they just happen, without being planned or intended. Nearly all the time, this is an advantage. However, some automatic thoughts can cause problems. CBT helps you learn to recognize and deal with them so they stop causing trouble.
Cognitive modification (maladaptive schemas)
Sometimes automatic thoughts turn out to have a shared theme (called a “schema”) that you may or may not have ever put into words or even be aware of. They take the form of basic assumptions, attitudes or beliefs that influence your thinking indirectly but powerfully. Common examples: “The world is a dangerous place,” or “I’m not a likable person.”
In CBT it is sometimes useful to identify these broad, persistent patterns of thought — which are usually half-truths at best — so you can be on the lookout for them and learn not to be misled by them.
Cognitive modification (irrational ideas)
Certain troublesome schemas are so common that they have found a place on Dr Albert Ellis’s famous list of Twelve Irrational Ideas. For example:
- It is an absolute necessity to have love and approval from others almost all the time
- People who harm me or commit misdeeds are evil, wicked, and villainous individuals, and I should severely blame, damn, and punish them.
Mindfulness
As noted above, the way we think can affect the way we feel. But even more importantly, our moods and emotions powerfully influence the way we think.
One way of directly altering moods and emotions is with chemical substances, including prescription medications, “recreational” or “street” drugs, alcohol and nicotine. The other major way is by acquiring and cultivating the skill of mindfulness or focused, non-judgmental attention. The techniques of mindfulness are borrowed from Buddhist meditation practices, particularly those of the Vipassana and Zen traditions. They have been shown to be effective parts of the treatment of depression and other conditions.
Exposure
If you habitually react with anxiety, fear or anger to particular events or situations, these reactions can be cut down to size with exposure procedures. Basically, this involves exposing yourself to the situations and remaining in them until the emotion diminishes, which takes only a few minutes providing you can resist escaping physically or mentally, and avoid catastrophic thoughts about not being able to cope. This is a challenging task which takes practice . Sometimes it is useful to rehearse being in such situations in your imagination (called imaginal exposure) before tackling them directly (in vivo exposure).
Activity scheduling
In depression and sometimes in anxiety conditions as well, it is common to avoid normal activities — either in an attempt to prevent emotional distress or because you lack normal energy. This is understandable, but its effect is to worsen and prolong the depression and anxiety. Activity Scheduling is a strategy for getting you up and moving so that you can experience more of the good things in life that you’ve been missing while you were trying in vain to avoid discomfort.
You and your therapist develop lists of activities that are usually either pleasurable in themselves or that give you greater control of your self and your environment. Then, you schedule times and places to carry them out in increasing “doses.” The underlying strategy is: “Do better now, feel better later.”
Interestingly, recent research evidence suggests that behavioural activation by itself may be able to do as much as explicit cognitive modification to change depressive thought patterns.
CBT and philosophy
The founder of CBT, Aaron T Beck, paid attention to the philosophy of Epictetus, who put great emphasis on the fact that it is not events by themselves that disturb us, but what we make of them. For example, if you are asleep in bed and hear a noise downstairs, you may think ‘oh lord a burglar’, or ‘it’s just the cat’ or ‘that’s my wastrel partner coming in drunk again’. Your feelings will be very different depending on which thought you have.
Another favourite was Socrates, famous for his commitment to unbiased enquiry, with a refusal to make assumptions. He used to accost shoppers in ancient times, ask them what they had in their basket. If they replied ‘a cabbage’ he would ask ‘how do you know?’. This kind of investigation is very useful for uncovering thought patterns we take for granted.
More recently Buddhist thought has been incorporated into CBT. The practice of mindfulness is the most obvious is embodied in a major world religion (or in another view, moral philosophy) and is thus much better known, if they could meet they would find themselves agreeing on many things. They . Both of them, moreover, counseled accepting whatever happens, while reserving our attention and effort for situations in which we can reasonably hope to influence the course of events. The latter principle is embodied in the well-known “Serenity Prayer”:
“Grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”
As you sow . . .
Now you have an idea of the kinds of things you may be doing in CBT. It has an excellent track record — in fact no other type of therapy approaches CBT in demonstrated effectiveness. Even so, it’s only as good as the effort and persistence you put into it. Plan on making your work in CBT a top priority for long enough to get the benefit of it.
[1] Founder of Rational-Emotive Behavior Therapy, a form of CBT.
[2] Birth name: Siddhartha Gautama.