Cognitive Behavioural Therapy or CBT is a tradition of psychotherapies that became most prominent and influential from the 1980’s to the early 2000’s. It is an active treatment in which the client develops skills to better manage distress and thoughts and behaviours associated with this distress.
CBT arose in opposition to Sigmund Freud’s psycho-analytic therapy that had been popular in the early 20th Century. Academic clinical psychologists had concerns about the lack of scientific rigour that they observed with psycho-analysis. The content for psycho-analysists seemed subjective and difficult to control. Therapists encouraged clients to free-associate, analysed dreams and made developmentally informed interpretations, all of which was difficult to verify and measure. The Behaviourist school of clinical psychology arose in direct opposition to the psycho-analysis. They chose to focus on things that they could reliably measure, such as how close an arachnophobe could get to a spider or how many times someone with Obsessive Compulsive Disorder has to check that the front door was locked before they could leave. The treatments that emerged from the behaviourism persist today and include behavioural activation for depression, exposure therapy for various phobia’s and contingency management strategies for children. The tradition, technically referred to as Behaviour Therapy (BT) until the 1980’s, had a reputation for being scientifically valid, brief and both clinically and cost-effective.
In the 1960’s and 70’s academic psychologists developed cognitive models of human behaviour and emotions. These models were Influenced by advances in computer science and focus on human’s ability to interpret, appraise and process information. In the early stages of the CBT tradition, the content of someone’s thoughts would have been too subjective for measurement and intervention, however, as is often the case, the intensity of the polemic against psychoanalysis had cooled, allowing cognitive therapy to establish itself. Cognitive therapy was based on the Cognitive Model. This model of human distress suggests that our emotions are causally linked to interpretations we make of situations we find ourselves in. For instance, one person may step inside a lift and believe that they will faint or go crazy, humiliate themselves, be forced to leave their job and then conclude they are a failure. This will almost certainly lead to anxiety and low mood. Another person may step inside the same lift and think to themselves that lifts go up and down hundreds of times each day and that there is a phone in case of emergency. This latter individual is likely to experience little distress. The cognitive model uses appraisals like these just described to explain distress. The therapy associated with the cognitive model teaches clients to identify their appraisals when they feel low, anxious or angry and challenge them in order to see the situation they are in more proportionally.
Mindfulness: The Third Wave of CBT
In the last 20 years ago, CBT has entered its third major revision. This has involved the addition of mindfulness. Mindfulness is a philosophical system with roots in eastern philosophy and is more than 3000 years old. Its clinical application emphasises cultivating present centred attention, developing a non-judgemental stance and equanimity, being non-reactive and letting go of our resistance and struggle against distress. Various innovative clinicians have adapted traditional CBT to include mindfulness. Examples include Dialectical Behaviour Therapy (DBT), Acceptance and Commitment Therapy (ACT), Mindfulness Based Cognitive Therapy (MBCT) and many more.
CBT is the most studied of all of the psychotherapies to date and has the most substantial evidence base. It has been used to treat people across the age range and has been applied successfully across an enormous range of psychological, relationship and health problems. It was initially developed to help people suffering from depressive and anxiety disorders, however over time it has been used to treat almost any problem that has a psychological component. It has demonstrated effectiveness with mood, anxiety (panic disorder, obsessive compulsive disorder, worry, social phobia) and anger problems and is considered a first line treatment for these problems. In more recent years, CBT has been used to treat major mental illness (delusions, hallucinations), drug and alcohol dependence, insomnia and relationships. Interestingly, CBT has been demonstrated to be effective in reducing disability and improving functioning with chronic health problems such as chronic pain, diabetes and chronic fatigue syndrome.
What does CBT consist of?
If you attend a psychologist and they implement a CBT treatment program this will most likely involve some behavioural component, cognitive therapy and mindfulness meditation. Most often the psychologist will take a few sessions to conduct a thorough assessment. They will then provide the client with a model or formulation of the problem that has been presented alongside a treatment plan outlining the cognitive, behavioural and mindfulness strategies that will be worked through.
In order for the client to understand the condition that they are presenting with the psychologist provides the client with “psycho-education”, an unfortunate term that refers to information about the psychological models of psychological disorders. For example, someone with social phobia would learn about the physiological (Eg tachycardia), cognitive (Eg “I’ll humiliate myself”) , attentional (Eg focus on what I’m doing with my hands rather than the topic I am presenting on) and behavioural (Eg avoidance of social situations) components of social anxiety.
Examples of behavioural strategies include; behavioural activation, exposure, pacing for those with pain or fatigue, contingency management and stimulus control for drug and alcohol problems.
Cognitive therapy involves monitoring your thoughts when distressed on specific monitoring forms. The client will then usually be taught to categorise their thoughts according to the cognitive bias in which they fit. Cognitive biases are stereotypical ways that humans distort information that relates to their emotions. For example, the Black and White thinking bias involves in people creating extreme, either-or categories in their beliefs. Someone is a success or a failure, they are gorgeous or hideous, they are good or bad, smart or stupid.
Finally, and most importantly, the beliefs and appraisals the client reports are challenged. The client learns to consider evidence for and against their belief, designs experiments to test out assumptions and generates alternative perspectives from their habitual interpretations. This often allows leads clients to identify less strongly with their thoughts and the intensity of their distress reduces.
When we teach mindfulness in this practice we usually start formally, using the meditation techniques that many would have encountered in their local yoga class or meditation drop-in class. People are encouraged to bring their awareness to their breath. When they inevitably drift off they are encouraged to notice where they have drifted to and with a gentleness, bring their awareness back, again and again. We then move on to incorporate more complex exercises, such as the “body scan” or mindfulness of thought. The ultimate goal is to equip the client with the ability to bring on a mindful mental state and get into the habit of doing this regularly. The psychological benefits of this are varied. It reduces rumination, promotes acceptance of difficulty (emotional distress, physical pain etc), reduces reactivity, reduces resistance and avoidance and allows for greater appreciation of positive, joyful experiences that occurs in someone’s experience.
CBT is a short-term treatment, commonly lasting between 6 and 20 sessions. It can appear simple, however it can be complex in its implementation. It is an active and directive treatment, requiring collaboration between the client and clinician. It requires that the client complete tasks outside of the therapy session and the client ideally develops the skills to treat and maintain their own therapy, effectively becoming their own psychologist.