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Cognitive Behavior Therapy (CBT) is a theoretical orientation based on a social learning model that highlights how an individual’s thinking impacts how he/she feels and how he/she behaves (Leahy, 1999). The concept that our perceptions determine how we experience reality has been documented as far back as “Plato’s Cave” when Socrates described how a group of men chained in a cave saw shadows dancing across the wall in front of them. The shadows are real to them until one day one of the men turns around and sees the shadows are cast by figures walking behind them. After that day, the shadows are no longer a reality. Leahy (1999) states cognitive therapy can be seen as an attempt to get the client to “unchain himself and see beyond the cave” (p.30). CBT is defined as a therapeutic approach used to explore connections to modify the way a person perceives situations and their reaction to those situations (Beck, 1995). CBT has clearly defined goals that involve reframing a person’s thoughts, beliefs, and perception in order to facilitate emotional and behavioral change (Leahy, 1999). This involves the interaction between thoughts, feeling and behaviors. CBT approaches therapy from the framework that the client is responsible for making the needed changes because he/she has contributed to his/her own psychological problems due to their thought’s effect on his/her emotional response and behavior (Beck, 1995; Ellis, 2004). According to Vivyan, (2009) “CBT says it’s not the event that causes our emotions, but how we interpret that event – what we think or what meaning we give that event or situation” (p. 39). Because thoughts influence a person’s emotional, behavioral, and physiological reaction, facilitating a person’s ability to evaluate his/her thinking, emotions, physiology and behavior could have a positive therapeutic effect (Beck, 2005). Additionally, it teaches clients to recognize and correct negative thoughts and beliefs that may be the cause of many of their problems (Beck, 2005). For example, exaggerated or biased ways of thinking can be maintained by stress and cause a person to experience depression, anger, or anxiety.
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Principles and Elements of Cognitive Behavior Therapy
The highlight of Cognitive Behavior Therapy (CBT) is the principle, based on the social learning theory, that our thinking impacts how we feel and behave. The focus of CBT is to identify negative or false beliefs and test or restructure them (Ellis, 1998). Further, CBT can be applied in many ways, to include concentrating on restructuring, modifying behavior, and/or developing alternative coping skills. The “B” part in CBT is behavior and involves a therapeutic approach that is goal-oriented and treats emotional and behavioral disorders as maladaptive learned responses that can be replaced by healthier responses through training (Williams & Garland, 2002). Additionally, CBT is present centered and focuses on what is happening in the current moment rather than exploring the past. It also makes it easier for clients to recognize and understand thoughts that may be leading to irrational worries and fears by being thought focused (Leahy, 1999).
Additionally, using a cognitive restructuring approach can help theclient and therapist explore cognitive distortions and this in turn can lead toa change in behavior through behavior modification (Williams & Garland,2002). In order to break the cycle, therapists help clients notice how theirthoughts and feelings affect their behavior, which can change what they think andwhat they do. Therapists who focus on CBT also help the client “deconstruct”his/her experience and recognize that the perception is what gives theexperience meaning (Leahy, 1999).
The behavioral component of CBT also includes respondent, cognitiveand operant conditioning in addition to addressing exposure and desensitization.Respondent conditioning is used to help clients construct their exposure toanxiety producing situations and thus reduce their sensitivity to the anxietyproducing events (Stangier, Schramm, Heidenreich, et al., 2014). Operantconditioning uses reinforcement and punishment to create associationsbetween behaviors and the consequence of those behaviors. This involves pairinga neutral cue with an aversive stimulus that causes a fear response to beelicited when the subsequent stimulus is presented to the now conditioned cue(Marin, Camprodon, Dougherty, & Milad, 2014). Operant conditioning alsoexplains why people do what they do and studying how both positive and negativereinforcers affect behavior can have practical use to treat some problems. Forexample, when working with a person who desires to change his/her behavior, thetherapist can find out what purpose the undesired behavior serves. Once that’sidentified a clinician can help him/her come up with behavior strategies tomodify that behavior and replace it with something healthier.
The most famousexample of classical conditioning is John Watson’s research with Little Albert.Watson conditioned him to fear by pairing a neutral stimulus (a white rabbit)with an unconditioned stimulus (a startling noise). This demonstrated thatpeople can develop an emotional response to a neutral stimulus (Masters,Burish, Hollon, & Rimm, 1987). This is seen in individuals that experiencetraumatic events who can be triggered by a neutral cue that has becomeaversive. For instance, someone who is held up at gunpoint while taking moneyout of an ATM will come to associate ATMs with this life-threatening event.ATMs can continue to elicit strong emotional responses weeks after thetraumatic event. Pavlov also modified behavior using classical conditioning. Hedid this by conditioning dogs to salivate at the sound of a tone. Understandingthat neutral stimuli can become aversive helps us understand why some peopledevelop anxiety disorders after experiencing anxiety-provoking events. Thesetheories of respondent, classical, and operant conditioning are used in CBT to helpclients identify distressing thoughts and employ behavioral therapy techniquesto modify their thoughts and behaviors (Marin, 2014). Further, CBT givestherapy structure and helps clients focus on challenging their belief patternsand correct their thinking errors. This is done by focusing on the presentingproblem in the current moment (Burns, 1999; Ellis, 1988). By helping the clientinterpret their experience in a different way the therapist and client worktogether to develop constructive ways of thinking that will produce healthierbehaviors and beliefs. Additionally, CBT enables therapists to stay focused bytaking interest in more than the client’s symptoms and life history. They alsogive attention to the client’s interpretation of his or her life events.Lastly, CBT allows therapists to set an agenda and structure the sessions byhaving clearly defined goals and this can be critical when time is limited(Leahy, 1999).
Techniques and Definitions of CBT
In order to help clients understand how their response to situationsaffects their behavior, CBT utilizes practiceand homework. The intent is to help clients learn new skills that assistthem in understanding the link between thoughts, feelings, and behaviors. Thismay involve issuing homework that allows them to test their beliefs againstreality, such as replacing negative thoughts with more realistic thoughts or byusing thought records by recording negative thoughts in a journal. By assigningand demonstrating homework the therapist takes on the role of a teacher orcoach who encourages clients to practice techniques learned during therapy(Creed et al., 2014). The following is alist of techniques and definitions used in this paper:
- Negative Cognitions/Thinking Errors: Thoughts and beliefs held by a client that can serve to limit their functioning.
- Relaxation response: A condition in which muscle tension, cortical activity, heart rate, and blood pressure decrease and breathing slows.
- Negative thought pattern: Any type of thinking that leads to negative consequences.
- Values Card Sort: Values define what an individual wants out of life and how he/she is going to behave to get it. They determine how an individual will use his/her time, energy and resources.
- Maladaptive Beliefs: False and unsubstantiated thinking that causes and maintains emotional problems.
- Diaphragmatic breathing: Breathing through progressive relaxation intended to relax the muscles and reduce anxiety.
Efficacy of CBT
Throughout this research, CBT was shown to be the most effectiveform of treatment for numerable forms of mental illnesses to include;depression, anxiety, panic disorders, chronic pain, eating disorders and addictions(Creed, Wolk, Feinberg, Evans, & Beck, 2014). The targets of CBT are preciselychosen to be measurable and studies have shown that individuals who undergo CBTbenefit in many ways. One of those is by improved brain activity suggestingthat CBT also improves brain functioning (Creed et al., 2014). According toPorto, Oliveira, Volchan, & Ventura (2009) CBT leads to neurobiologicalchanges in anxiety disorders (as detected by neuroimaging techniques). CBT “modifiedthe neural circuits involved in the regulation of negative emotions and fearextinction in judged treatment responders” (Porto et. al, 2009, p 114).Neuroimaging studies also revealed that dysfunctions of the nervous system werechanged due to CBT, although there were methodological limitations, (Porto etal., 2009).
Functional analysis of behavior is considered to be the heart ofCBT. According to Scharwachter (2008) the link between clinical practice and experimentallyverified learning principles is what helps explain the consequences of behavior.Hanley, Iwata, and McCord (2003) further define functional analysis as an examinationof the causes and consequences of problem behavior. In addition, they explainfunctional analysis as being influenced by the individual’s environment wherethe consequences of behavior can reinforce or punish behavior that will make itless or more likely for the behavior to be repeated in the future. Using functionalanalysis helps therapists generate hypotheses to explain the motives that keepproblem behaviors going which can assist clients in selecting techniques to bestaddress the behavior During treatment, using functional analysis helps identifyevents where the client has difficulty coping or circumstances that may triggerthe client.
Some of the mental disorders that can benefit from the functionalanalysis of CBT include: anxiety, depression, dissociative identity disorder,eating disorders, generalized anxiety disorder, hypochondriasis, insomnia,obsessive-compulsive disorder, and panic disorder without agoraphobia (Hanley,Iwata, & McCord, 2003). A successful tool used in functional analysisincludes homework that allows clients to identify the antecedents, behavior,and consequences of that behavior (Hanley, Iwata & McCord, 2003). Anexample of this is the therapist conducting a functional analysis of a recentepisode of avoidance, cognitive distortions, or self-defeating behavior withthe client in order to identify the cause of the behavior. The environmentalfunctions of both wanted and unwanted behavior needs to be explored in order toachieve a conceptual position of the client’s behavior. One way to investigatethis is by having the client think about the memory and explore what was goingon during the time they were trying to avoid the situation or cognitivedistortion, such as how they were feeling, what was going on before and afterthe event, and the positive and negative consequences. This includes exploringwhat they saw, where they were, what they were smelling, hearing, andtasting.
Casey is a 31-year-old Caucasian woman who reported depression andanxiety that she stated stemmed from negative feelings about herself, lowself-esteem and a history of self-harm and substance abuse. She depictedfeeling hopeless, crying uncontrollably, losing interest in activities she usedto enjoy, significant weight loss, fatigue, low self-esteem, and an inabilityto sleep. She described a “negative thought pattern” consisting of negativecognitions about her abilities and aptitudes which disclosed she experienced areality that was different from her ideal self. She identified not feeling shewas “worthy” of being loved because she had done “unforgivable things.” Shealso reported not knowing who she was and “losing” herself in relationships bybecoming whoever she thought her partner wanted her to be. During the secondappointment after the intake interview, which included her psychologicalhistory, trauma, and family history, I introduced the rationale for CBTtreatment, and went over the structure for the following sessions. I asked theclient what her goals were and she appeared to have good insight into herpresenting problems and stated she wanted to “do something other than talk.”She appeared to be motivated to change and eager to find out why she was socritical of herself. During our initial session, Casey expressed she did wellwith homework because she needed to have defined and achievable goals. Thishelped guide our sessions using a CBT approach.
After the initial appointment, I introduced CBT and talked aboutstarting skills training. We went over the CBT skills workbook together andCasey chose what she wanted to focus on based on what she identified as causingher the most hardship. We agreed that in subsequent sessions we would go overthe homework together and she would pick the assignment for the following week.We also agreed that as time went on I would sometimes make suggestions on whather following assignment should be based on her concerns in the session.
I also set the agenda for future sessions into three parts, althoughthis agenda remained flexible and was intended to set a structure for ourmeetings, which is something Casey stated she found comforting. During thefirst part, which was scheduled to last from 10 – 15 minutes I would check inwith Casey, listen to her concerns, and ask if there was anything she wanted tomake sure we covered. During the second part, which was scheduled to lastapproximately 20 – 30 minutes, the agenda was introduced and the topic was correlatedto address Casey’s current concerns. During the remainder of the time possiblehigh risk situations were discussed, Casey’s understanding of the topic wasexplored, and homework for the following week was assigned. During follow upsession she was eager to go over her homework and talk about what it hadbrought up for her and how she was utilizing her newfound skills.
Some of the symptoms she revealed she was experiencing were considered,such as social withdrawal and a sense of worthlessness which includeddepression and feeling useless. She identified isolating herself and drinkingto get drunk in order to keep people from getting close to her. She stated shedid this out of fear that others would discover she was a “fraud.” She alsoreported believing other people “tolerated” being around her but she did notbelieve people actually wanted to be around her. When asked to list what shedid well she shrugged her shoulders, looked at the floor, and could not name anythingshe felt she did well. When asked to list what she did not do well she becameenergized and immediately began to list things she was not good at until Istopped her to point out how difficult it was for her to identify things shedid well but how quick she was able to identify the things she was not doingwell.
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When inquiring where the cognitive distortions and automaticnegative thoughts came from, such as “I should be perfect” and “I am worthless”we uncovered that those were messages she received from her mother and had internalized.Her assumption was that people would discover she was a “fraud” if they got toknow her and her automatic thought was that she would be rejected and otherswould find her to be boring. She also blamed herself when her relationshipsfailed stating it was because she was not able to “be herself.” This self-doubtwas caused by the shame she carried due to her previous drug use.
She was then asked to keep track of her negative thoughts as theycame up during the day by using a Dysfunctional Thought Record. The tool weused to do this was pulled out of a functional analysis worksheet found on theCBT workbook. The first column was the situation that provoked an emotionalresponse; the second column was the feeling that came up during the situation;the third column listed her automatic thoughts; and the fourth column was the alternateresponse possible that could help her identify different ways she could thinkof the situation to help her restructure her thoughts. The goal was to explorethe origin of those cognitive distortions that were reinforcing the belief thatshe was worthlessness and unlovable because it was contributing to hermaladaptive responses in relationships
She also identified a history of previous suicide attempts, drug use,running away from home, staying in abusive relationships, continually moving to“get away from” herself and quitting jobs. She stated she quit her jobs becauseshe felt she never did a good enough job and this was “proof” of herinadequacy.
Additionally, I handed her a list of negative cognitions andpositive cognitions and I challenged her cognitive distortions by interruptingher thought pattern and asking her to replace it with a more positive one, suchas, “I have value.” When she declared anautomatic negative thought, I would point it out and ask her to reword it and replaceit with a positive cognition. For instance, when she said “should” statements,such as, “I should have done better on the test” I would ask her to rephrase itand she would look at the list of negative and positive cognitions and rephraseit with a positive cognition, such as “I did the best I could.” We continued todo this with other cognitive distortions that were contributing to her lowself-esteem. Additionally, she took a picture of the list of negative andpositive cognitions and stated she would pull it up whenever she caught herselfbeing self-critical. She indicated she would replace maladaptive assumptionswith practical assumptions, such as changing the following statement, “I’m afailure if I don’t get a perfect score on a test” to something morerealistic, like “Everyone makes mistakes and I don’t have to be perfect.” Wediscussed the consequences of negative thinking and how it could continue to bean obstacle to self-change and lead to unhappiness.
Casey prided herself on being fit and stated she found yoga to behelpful in feeling calm and grounded. When she identified feeling overwhelmedby her demanding school work as a nursing student and her job as a medicalassistant, I decided to teach her relaxation techniques and mental distractionsin order to help her reduce stress and improve her mood. We also practiceddiaphragmatic breathing to interrupt her racing thoughts by having her repeat,“I am calm, I am peaceful” when she exhaled. I also used visualization byhaving her look out the window and identify the vastness of the sky. Wepracticed sitting with our feet firmly planted on the ground, feeling the goodenergy come out of the earth and through the body lifting the negative thoughtand throwing it at the sky. The exercise was a visualization technique whereshe would toss her worry at the sky and let it go.
In order to help Casey identify who she is and what she stands for, Iturned to values-based work by using the card sort. This is an interactiveexperience used to help her figure out what she finds important and how she isliving her life according to her values. As a result, we were able to definegoals more clearly and work together on ways she could stay true to herself andlive according to her values. I also put the values she chose on the table and whenevershe talked about something she was doing that aligned with her values I wouldpoint to the card in order to highlight the value she was living up. If shementioned doing something that did I knew did not align with her values I wouldask her how that aligned with her values and we would discuss what motivatedthe behavior and she would explore how she could modify it. My goal was to helpher recognize her negative thinking and how it might be causing her anxiety anddepression. She identified the need to be perfect and this could have beenkeeping her trapped in her own unrealistic standards.
Limitations and Strengths
One of the goals of CBT is to lessen dependence on the therapist bybuilding a collaborative relationship and fostering autonomy in the client(Beck, 1995). This approach may appeal to clients who have limited time and/ormoney to go to therapy. Since the directive skills of CBT can be learned on anaverage of 16 weeks and can later be conducted on their own, this may havelifelong effects in a shorter time than other therapeutic methods (Beck, 1995).This is also helpful during practicum and internship when time is limited toone or two semesters. Furthermore, having structured sessions reduces thepossibility that sessions become “venting sessions” and the limited time may allowfor more therapeutic work to be accomplished. On the other hand, clients may feelthe focus on positive thinking minimizes the importance of their personalhistory and the impact on external factors (Ellis, 1998). Other clients may feelCBT intellectualizes their emotions which may feel superficial to them (Burns,1999). Additionally, CBT many not be appropriate for clients with traumaticbrain injury or a brain disease that impedes their ability to participate intheir treatment. Lastly, CBT many not appeal to clients who are not willing totake an active role in their treatment process or clients who do not want to beburdened by homework.
Barriers and Facilitators
Cultural values and beliefs can be a barrier to therapists when working with an unfamiliar culture. I was working with an Alaskan Native client who corrected my approach by helping me understand that asking him to focus on himself came across as selfish and a better way to help him would be to reframe therapy in a more collectivistic approach that helped him think he was giving back to his family and community. This taught me that I need to ask myself if I knew who I was talking to and if I had prepared myself to talk to them in a way that was beneficial and culturally sensitive so our time together would be constructive for them.
For the most part I found CBT to be effective based on client’s self-report of being able to question the validity of their automatic negative thoughts and replace them with more accurate and balanced alternatives. Additionally, CBT encourages clients to challenge distorted thoughts and change destructive patterns of behavior by focusing on solutions. Another benefit of CBT is that it is simple to convey and most clients find it easy to understand and implement. However, one of the most telling factors that CBT will be beneficial for a client is his/her willingness and ability to be open to reframing their cognitive distortions. Lastly, having a supervisor who was knowledgeable about CBT and took the time to listen and instruct me on the tools available for CBT has been invaluable in helping me understand and implement therapy in a way that feels genuine.
I’m drawn towards this therapeutic approach because it aligns with my personal values of self-reliance and autonomy. Cognitive Behavior Therapy is an approach to therapy that has more studies than any other theoretical orientation because it focuses on the present situations clients want to change and targets the thoughts and behaviors that are maintaining the problem behavior. It also helps clients look for ways to immediately improve their wellbeing. Additionally, CBT offers treatment goals that are easy to measure and implement. My military background has given me a solution focused attitude and an appreciation that aligns with CBT because it is measurable and encourages clients to take action towards their recovery. Most importantly, it empowers clients by giving them a sense of control over their lives and offers them coping skills and solutions they can implement on their own outside of therapy.
- APA Presidential Task Force on Evidence Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61, 271-285.
- Beck, A. (2011). Cognitive Behavior Therapy: Basics & Beyond. New York, NY: Guilford
- Beck, A. (1995). Cognitive Therapy: Basics & Beyond. New York, NY: Guilford
- Beck, A. (2005). The current state of cognitive therapy; a 40-year retrospective. Archives of General Psychiatry, 62, 953-959.
- Burns, D. (1999). Feeling good handbook (rev. ed.). New York, NY: Plume
- Creed, T., Wolk, C., Feinberg, B., Evans, A., & Beck, A. (2014). Beyond the Label: Relationship between community therapists’ self-report of a cognitive behavioral therapy orientation and observed skills. Administration and Policy in Mental Health and Mental Health Services Research, 43 (1), 36-43.
- Ellis, A. (1998). How to stubbornly refuse to make yourself miserable about anything. New York, NY: Citadel Press.
- Ellis, A. (2004). Rational Emotive Behavior Therapy: It works for me – It can work for you. Amherst, NY: Prometheus Books.
- Hanley, G., Iwata, B., McCord, B. (2003). Functional analysis of problem behavior: a review. Journal of Applied Behavior Analysis, 36(2), 147-185. doi: 10.1901/jaba.2003.36-147
- Leahy, R. (1999). Strategic Self-Limitation. Journal of Cognitive Psychotherapy, 13(4), 275-293.
- Marin, M., Camprodon, J., Dougherty, D., Milad, M., (2014). Device-based brain stimulation to augment fear extinction: Implications for PTSD treatment and beyond. Depression and Anxiety, 31, 269-278. Doi: 10.1002/da.22252
- Master, J., Burish, T., Hollon, S., & Rimm, D. (1987). Behavior therapy: Techniques and empirical findings, (3rd ed.). New York, NY: Harcourt Brace Yovanovich College Publishers.
- National Alliance on Mental Illness (2016). Psychotherapy. Retrieved April 27, 2016 from https://www.nami.org/learn-more/treatment/psychotherapy
- NIDA Publication: A Cognitive-Behavioral Approach: Treating Cocaine Addiction. Retrieved April 26, 2016 from http://www.drugabuse.gov/txmanuals/cbt/CBT1.html
- Porto, R., Oliveira, L., Mari, J., Volchan, E., Figueira, I., Ventura, P. (2009). Does cognitive behavioral therapy change the brain? A systematic review of neuroimaging in anxiety disorders. The Journal of Neuropsychiatry & Clinical Neurosciences, 21(2), 114-125.
- Scharwachter, P. (2008). Three Applications of Functional Analysis with Group Dynamic Cognitive Behavioral Group Therapy. International Journal of Group Psychotherapy, 58 (1), 55-76.
- Stangier, U., Schramm, E., Heidenreich, T. (2011). Cognitive therapy vs Interpersonal Psychotherapy in Social Anxiety Disorder, a Randomized Control Trial. Archives of General Psychiatry, 68, 692-700.
- Williams, C. & Garland, A. (2002). A cognitive behavioral therapy assessment model for use in everyday clinical practice. Advances in Psychiatric Treatment, 8(3), 172-179. doi: 10.1192/apt.8.3.172
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- 5 CBT Techniques to Counteract the Negative Thinking of Depression. ...
- Locate the problem and brainstorm solutions. ...
- Write self-statements to counteract negative thoughts. ...
- Find new opportunities to think positive thoughts. ...
- Finish each day by visualizing its best parts.
Many studies have found that self-directed CBT can be very effective. Two reviews that each included over 30 studies (see references below) found that self-help treatment significantly reduced both anxiety and depression, especially when the treatments used CBT techniques.
- Cognitive restructuring or reframing. ...
- Guided discovery. ...
- Exposure therapy. ...
- Journaling and thought records. ...
- Activity scheduling and behavior activation. ...
- Behavioral experiments. ...
- Relaxation and stress reduction techniques. ...
- Role playing.
- What were you feeling right before you did that? (Affective)
- What happens to you physically before this happens? ...
- How do you normally act right before this happens? (Behavioral)
- What thoughts go through your mind before this happens? (Cognitive)
Research shows that CBT is the most effective form of treatment for those coping with depression and anxiety. CBT alone is 50-75% effective for overcoming depression and anxiety after 5 – 15 modules. Medication alone is effective, however, science still does not understand the long-term effects on the brain and body.
Cognitive behavioral therapy exercises are designed to intervene on all three components simultaneously. For instance, when uncontrollable worry is the problem, CBT exercises can help people to identify more effective and grounded thoughts, which lessens anxiety.