Cognitive Behavioural Therapy (CBT) is a problem-focused approach; therefore treatments are typically brief and time-limited in nature. Many online CBT treatments lead to significant clinical improvement and symptom reduction, relative to other forms of psychotherapy, in as few as 10–20 sessions.
Over the past 50 years, cognitive-behavioural therapies (CBT) have become an effective mainstream psychological treatment for emotional and behavioural problems.
CBT is a joint venture between therapist and client with the aim of exploring beliefs and interpretations about oneself, others and the world. It offers a specific set of strategies, which allow the client to become more aware of their own thoughts and images in relation to external events or internal sensations. Once the client is able to identify their thoughts it becomes possible to target distortions or biases in thinking, which may be leading to such states as anxiety or depression.
These maladaptive/distorted thoughts (appraisals) or images are the focus of intervention and are targeted in conjunction with behavioural plans and experiments. Predictions about oneself or the outcome of events are systematically tested out in order to acquire new information, which can then be used to form the basis of new insight or interpretations.
Whenever you experience an unpleasant feeling or sensation, try to recall what thoughts you had been having prior to this feeling (Beck, 1976, p.33).
In the beginning, the therapist’s role is to gather information and develop a hypothesis about the client’s concerns. The hypotheses will encompass predisposing factors (such as childhood or significant life events), precipitating factors (such as a recent death, break-up or event), and perpetuating factors (such as negative beliefs about others or lack of assertiveness). The hypotheses will aim to encompass all of these factors in relation to specific symptoms, current emotional states and use this as a platform for treatment.
The CBT therapist operates according to a scientific methodology, whereby a detailed account of the client’s concerns are taken, a hypothesis is made, shared and agreed on with the client and behavioural experiments planned. Once a behavioural experiment has taken place this information is further taken into account into the hypotheses and this generates continuous readjustment.
The CBT model encompasses the following characteristics:
1. Through life experience, a person develops both adaptive and maladaptive thoughts/assumptions/beliefs about themselves, others and the world. These thoughts are easily triggered in the process of everyday interactions and events.
2. Maladaptive thoughts may contain a number of distortions; they are too confining, too extensive, too severe, or simply inaccurate.
3. Individual’s day-to-day dysfunctional/maladaptive thoughts derive from dysfunctional/maladaptive core beliefs (Deeply held beliefs about oneself, others and the world).
4. These maladaptive core beliefs are predominantly developed from childhood experiences.
5. As cognitive therapy is a present-focused approach, uncovering childhood experiences is not required. Rather the information required for Cognitive Behaviour Therapy is taken from the client’s current interactions within the world.
Cognitive Behaviour Therapy has developed a system of thought, which aims to understand how thoughts and perceptions based on prior learning experiences interfere with current processing of events and the world.
More ‘common sense’ beliefs would predict that it is events and people that make one feel upset or happy, but the cognitive model differs in respect to this as it shows that it is our interpretation of events, which is the cause of emotional reactions/distress.
This can be easily understood by observing individual reactions to the same or similar events. Imagine there were three people who all experience the exact same event. The event is waking up on the morning of your birthday, seeing a couple of members of your family who don’t wish you a happy birthday and subsequently leave for work or other events.
Person A may think: “Nobody really cares about me, I’m not worth caring about.” Feeling: Sadness.
Person B may think: “Oh, those thoughtless idiots, I’ll remember this when it’s their birthday.” Feeing: Anger
Person C may think: “They must be planning something for later,” or “I’ll remind them later, I’m sure they are busy now.” Feeling: Hopeful/Optimistic
Why do people think in such different ways? It’s a matter of previous life experiences, the interpretation of the current situation and current states of physiological arousal.
“People are disturbed not by things, but by the view which they take of them” (Ellis & Dryden, 1997).
We all think negatively at times, which ultimately makes us feel bad. What makes us feel depressed, anxious, or panicked is consistently thinking in this way.
CBT focuses on uncovering the thoughts, emotions and behaviour of clients in relation to the environment. To begin we must first strive to understand how our thoughts are related to negative emotions or behaviour.
The crux of CBT is the collaborative relationship between therapist and client. As Therapy is generally only once a week, it is the client’s responsibility to collect information between sessions that can be used within sessions. CBT generally begins with solving present problems before restructuring the past and moving on to future concerns.
The ABC model (See Chart) offers a useful way of viewing the relationship between events thoughts and emotions and for the client to collect information. Within this model the ‘A’ stands for Activating Event, this refers to the situation at the time of the feeling or thought, from what is observed to what is actually said to you or by you, even to you. The ‘B’ represents your belief or thought, this is the interpretation you give to the event, and this can also be any images that occur to you at the time. The ‘C’ represents the Consequences to you and is divided into Consequences that are emotional and Consequences that are behavioural. Emotional consequences are how you feel, which might be sad, anxious, angry etc. Behavioural consequences are what you do, maybe you’ll cry, run away or simply avoid the situation.
To begin to familiarise yourself with this model it is probably best to initially notice any feelings you may have, this is the ‘C’ component. These are usually the first things you’ll become aware of, as it will represent a change in your mood. From here you can identify the ‘A’ by asking yourself “what just happened.” It is now time to find the ‘B’ your thought or interpretation about the event that has made you feel a certain way. Once the ‘B’ is identified you are now in a position to begin to distance yourself from your thought and examine its relationship to history, distortions, biases, the present and future.
A: Activating Event
What was happening at the time? What was said?
What did you see?
What have you just said or told yourself to make
you feel this way?
Emotional: How did you feel?
Behavioural: What did you do?
|Example 1: PanicApproaching a packed bus, train or elevator.
|I won’t be able to breathe.I’ll panic and lose control.I’ll have a heart attackPeople will think I’m weird or insane.
|Emotional: Sweating, Heart pounding, Shaky.Behavioural: Drank lots of water. Looked along
all carriages to find an empty one. Decided to take the next train.
|Example 2: Social AnxietyEntering a crowded room
|I won’t know what to say.I won’t be able to think of anything and i’ll look stupid.I’ll get really nervous and not be able to control my shaking or sweating.They’ll all think i’m weird and laugh at me/think bad of me.
|Emotional: Anxious, Sweating, Heart-Pounding, Tense.Behavioural: Avoid the Situation. Grip glass tightly.
Only engage in conversation for brief periods then walk away. Stick with one person for the whole night. Don’t talk to anyone.
|Example 3: DepressionPartner or Friend doesn’t return your phone call at a specific time.
|They don’t care about me anymore.They never really liked me they were only here as they felt sorry for me.Our relationship is going to get worse, soon we won’t speak and then we’ll never see each other again.
|Emotional: Sad, Lethargic, Tearful.Behavioural: Don’t phone friend or partner to see what’s happening. Expect the worse. Take action on worst expectations.
|Example 4: Generalised AnxietyYou have a job interview the next day.
|What if I my car breaks down.What if they ask me a certain question.What if I get sick?What if my face turns red?
|Emotional: Anxious, Panicked, Fearful.Behavioural: Procrastination. Problems Focusing on Task. Problems with Sleep.
|Example 5: BereavementPassing of a family member or close friend.
|I can’t cope.There is no future without them.How can I go on?
|Emotional: Hopeless, Tearful, Lethargic.Behavioural: Lay in bed. Don’t go out anymore. Change quality and tone of voice.
These distortions are biases towards negative perceptions of yourself and events. Anxiety is an inappropriate bias towards danger about oneself of others. Social anxiety is a bias towards social danger, such as humiliation. Panic is a bias towards internal physiological danger leading to catastrophe; and depression is a bias towards negative expectations and memory recall, which affects perceptions about oneself and the environment.
Within CBT the behaviour exhibited by the client is deemed to be functionally related to the environmental events surrounding it including internal sensations. Therefore behaviour and physical states are amenable to therapeutic intervention. CBT is therefore designed to target specific symptoms and behaviours that are identified as a part of the diagnosis or presenting a problem for treatment.
Psychological problems can be mastered by sharpening discriminations, correcting misconceptions and learning more adaptive attitudes. Since introspection, insight, reality testing, and learning are basically cognitive processes, this approach to the neuroses has been labelled cognitive therapy (Beck, 1976, p.20).
The process of CBT focuses on the core feature of experience that leads to maladaptive assumptions, which are exhibited through negative thoughts/perceptions and altered behaviour patterns. This central feature is then subject to cognitive restructuring and behavioural experiments.
For example, a client living with Generalised Anxiety Disorder might believe that worrying helps to control outcomes about events. Therefore the core feature is a need for control in relation to outcomes. Worrying is then targeted to show that worrying has no consequences in relation to the environment only to cause internal distress.
Change or improvement in CBT is affected through the engagement in new experiences which lead to less distorted and biased interpretations about oneself and the environment. Examining predictions or beliefs about the feared outcomes of events also brings about change. Once this information is obtained a behavioural activation plan can be implemented in order to examine beliefs or interpretations about events. Progress is therefore made when new information is obtained about events, which then leads to the examination of biases and distortions in thought. This can lead to new relationships with events and new thinking patterns.
Generalised Anxiety Disorder (Excessive Worrying)
We all worry and feel nervous at times about the onset of events or events that have happened and our performance within them. However, people who may be described as chronic worriers are often disturbed that they seem to spend much of their waking hours worrying excessively about a number of different life circumstances. Worrying becomes generalised anxiety if it can be said to be generally excessive, persistent, intrusive and seemingly uncontrollable. Worrying can be said to be a sort of problem-solving activity but in this case, the problem is never solved.
Some symptoms of Generalised Anxiety include restlessness, fatigue, problems with concentration, irritability, muscle tension, and/or insomnia. Including worry about a variety of events, such as health, financial problems, rejection, and performance. Many people with GAD feel that their worry will make them physically or mentally unwell or make them go lose their mind.
Social Anxiety – Phobia
Social anxiety is the fear of one or more social situations. Commonly feared situations include public speaking, meeting new people, being at parties, asking for dates, eating in public, using public restrooms, speaking to people in authority, and disagreeing with others (confrontation).
Social anxiety is used to describe the anxiety that occurs in response to social situations, whether you are in the situation or thinking about the situation. Generally, many people do feel anxious about some social situations, such as giving a speech or talking in a group. Worrying about whether the speech will go well, or what other people will think is quite common. It is not uncommon for many speakers to feel this but go on to give the speech with anxiety decreasing as the speech goes on, feeling quite relieved when it is over. For others, the anxiety may be so distressing that they avoid the situation at all costs.
People with social anxiety are fearful they will act in ways that will make other people think badly of them (social humiliation). They often fear that others will see some sign of anxiety, such as blushing, trembling, or sweating. People with social anxiety usually try to avoid anxiety-provoking situations. If this is not possible, they tend to feel very anxious or embarrassed and think that everybody has noticed. Social phobia is a severe, disabling form of shyness and can cause problems in people’s lives. These problems range from sleeplessness, fatigue, tension, stress, avoidance of social situations, avoidance of confrontation, planning of social activities or interactions and an inability to stop dwelling or thinking about recent events.
Depression is usually defined as a mood disorder, with a negative outlook about oneself, the future and the world. Mood fluctuations are normal and help inform us that something is missing in the way we want our lives and give us some incentive to change things. However, individuals who are depressed, describe a low mood that has persisted for longer than two weeks. Depression has a variety of symptoms, such as loss of energy, loss of interest in activities and in life, sadness, loss of appetite and weight, difficulty concentrating, self-criticism, feelings of hopelessness, physical complaints, withdrawal from other people, irritability, difficulty making decisions (procrastination) and possibly suicidal thinking. Depression can sometimes be associated with low self-esteem, with feelings of worthlessness, inadequacy, shame and guilt.
With milder forms of depression it is possible not to feel bad all day but still have a dismal outlook about life. The mood may lift with a positive experience, but fall again with even a minor disappointment or when a challenge is met. With severe depression, a low mood could persist throughout the day, failing to lift even when enjoyable events occur.
Obsessive-Compulsive Disorder (OCD)
OCD is characterized by recurrent obsessions or compulsions that may be causing a significant amount of distress. The obsessions or compulsions may interfere with an individual’s life-impacting on their social, occupational, relational, educational or general functioning. An individual with OCD does not necessarily have to have obsessions and compulsions but one or the other may be dominant.
Obsessions can be persistent upsetting ideas, thoughts or impulses that are recurrent and cause anxiety or distress. The individual perceives them to be uncontrollable and intrusive to their daily functioning. Commonly thoughts may revolve around fear of contamination, illness, doing something embarrassing or immoral, hurting someone or forgetting to perform an action that can lead to disaster. Generally, individuals then engage in acts to try and neutralise them.
Compulsions are behaviours that are repeated in order to avoid danger or anxiety. These may manifest in such ways as hand washing, ordering and alignment of objects, checking (doors, taps, oven, electrical sockets, bins, empty spaces etc.), reactions such as turning lights on and off a number of times and hoarding (papers, tins, used goods).
The goal of a compulsion is to prevent danger and ultimately to reduce anxiety. Generally, people with OCD are aware that their compulsion is irrational and can’t alleviate the danger, however, they are still drawn continuously to complete the thought or action.
Panic Disorder and Agoraphobia
Panic attacks are defined as extreme anxiety or heightened physical sensations or symptoms that appear to come out of the blue. It’s very common to feel anxious or nervous, indeed it’s a natural arousal state that alerts us and prepares us for danger. A panic attack involves such an extreme level of arousal it can feel as if you are having a heart attack, going insane, or losing control of yourself. Common symptoms people feel during a panic attack are shortness of breath, tingling sensations, ringing in your ears, a sense of impending doom, trembling, a feeling of choking, chest pain, sweating, and heart-pounding. Panic can become a disorder if they become quite frequent in response to certain events and then you change your behaviour or actions in order to avoid or cope with these events.
Alongside panic or as a result of consistent felt panic states agoraphobia may develop which, is fear of places or situations where a panic attack may occur or from which escape might be difficult. A person with agoraphobia may avoid going out alone, going to supermarkets, travelling in trains or aeroplanes, crossing bridges, being at heights, going through tunnels, crossing open fields, and riding in elevators.
Cognitive-behaviour therapy has been shown in numerous studies to be extremely effective in combating panic and anxiety, with approximately 80% of people experiencing normal anxiety levels, usually within eight to ten treatment sessions.
Cognitive-behaviour treatment for panic can be identified by its two interwoven approaches, which are identifying and changing the distorted thinking patterns that maintain panic and anxiety and desensitizing anxiety through exposure to feared situations.