WHAT IS CBT?
The idea that our thoughts, attitudes, and beliefs have
a profound influence on the way we feel and react to what life throws at
us has been around for centuries; since the early Greek philosophers. The
scientific discipline of psychology has however only recently given attention
to this phenomenon as a means of understanding and treating psychological
problems. While the initial psychological theory of human emotion and behaviour
(originally based on the work of Sigmund Freud), certainly made significant
contributions toward the development of the profession, few theoretical
frameworks have had as significant an impact on the treatment of psychological
distress as cognitive behaviour therapy (CBT). The primary difference between
CBT and other psychotherapy models is based on the notion that emotional
and behavioural disturbance is essentially driven by the way in which we
think about that with which we are confronted. The fictitious scenario below
provides an example of the type of thinking that would typically be associated
with depressed mood.
Example: Joe fails his economics exam and thinks "I am such a failure;
I'll never manage to get through this degree; the rest of my life is ruined".
As a result Joe (1) feels depressed, (2) withdraws himself, (3) renders
himself helpless and his situation hopeless and (4) drops out prematurely
from his studies.
Alternatively, if Joe was able to think in a more helpful and realistic
manner and consider the following thoughts such as, "oh well, I failed,
but then who hasn't? This is a real inconvenience, but is it really a catastrophe?
I could certainly learn from my mistakes and try again; this isn't the only
thing I can study or do with my life", then he'd be more likely to
(1) feel sad or disappointed but not feel depressed, (2) not withdraw himself
or (3) not give up prematurely.
His disappointment would be considered healthy and may actually help motivate
him to try harder next time. This fictitious account provides for a typical
example of how our emotional and behavioural reactions to difficult circumstances
are determined to a large degree by the way in which we think about our
circumstances, and not merely by those circumstances themselves. In other
words, Joe's emotional and behavioural reaction is determined by how he
thinks about the fact that he failed, and not solely his failure.
CBT theory proposes that if we are able to identify those thinking and behavioural
patterns that are contributing toward our distress, restructure and alter
these, then one would be better equipped to reduce or eliminate psychological
distress. The CBT model thus encourages "emotional responsibility"
by encouraging individuals to identify and alter the way in which they think
so as to feel and react in a more appropriate way. This also provides for
a more optimistic view regarding the potential for human beings to alter
their emotional and behavioural reactions to difficult circumstances. The
model proposes that individuals can effectively and successfully influence
their own emotional well-being, irrespective of the situation with which
they are confronted.
CBT is practical, goal orientated and based on objective, measurable
concepts that have been verified scientifically (empirically). For instance,
behaviour can be observed, measured and studied, as can thought, which
we are typically able to articulate through language. Scientific investigation
has shown that our thoughts are very much associated with our emotional
states and behavioural reactions and that restructuring of our thoughts
typically alters the way we feel. Thousands of well designed, peer-reviewed
research papers have verified the central tenets of CBT. CBT-based intervention
is based on what we now know works regarding the treatment of a wide variety
of psychological disorders. There is ample scientific evidence that
CBT is effective in the treatment of mood disorders, anxiety disorders,
interpersonal problems, eating disorders, substance-related problems,
psychotic disorders, impulse control disorders, insomnia and behavioural
problems. Treatment is often based on a specific protocol, with brief,
direct, and time-limited treatments for specific psychological disorders.
CONCEPTUAL SCHEMA
EXPLAINING CBT THEORY?
The CBT model typically uses a schematic commonly referred
to as the A-B-C model of emotional and behavioural disturbance. (A) in the
model typically refers to the Activating Event or adverse situation with
which the individual is confronted. This could be a difficult interpersonal
interaction, a stressful situation at work, a physical sensation, thought
or emotional reaction. (B) refers to the thoughts or Beliefs that one then
responds to the activating event with, which is then seen as responsible
for initiating or maintaining (C), the Emotional and Behavioural Consequences
to these beliefs. The three examples below illustrate the model using a
typical scenario with panic disorder, OCD and depression.
EXAMPLE 1: PANIC DISORDER |
A - ACTIVATING EVENT |
B - BELIEFS |
C - CONSEQUENCES |
Driving on the N1 in the car.
Slight increase in body temperature + the thought - "what if
I have a panic attack". |
"I have to control this
anxiety".
"I'm not in control of myself".
"I will have an accident" |
Increased Anxiety & Panic
Pull car over
Use of a tranquiliser
Avoid driving on the N1 |
|
EXAMPLE 2: OCD |
A - ACTIVATING EVENT |
B - BELIEFS |
C - CONSEQUENCES |
Sitting in the kitchen with a
loved one, close to a large knife and the thought "what if I
stab my wife" pops into my head |
"This is an abnormal thought
that I shouldn't be having".
"This thought makes me dangerous".
"Thinking this increases the chance of acting on it". |
Anxiety
Guilt
Shame
Escape from Room
Prayer to get rid of thought |
|
EXAMPLE 3: DEPRESSION |
A - ACTIVATING EVENT |
B - BELIEFS |
C - CONSEQUENCES |
Recently rejected by a boyfriend.
Feeling sad and disappointed |
"I should have been able
to prevent this if I was good enough."
"If I was a worthwhile partner then this wouldn't have happened."
"I'm unlovable."
"I can't handle feeling this way"
"I'm never going to find someone" |
Depressed
Socially withdrawn
Ruminating about why this happened. |
|
The schematic would often include a second section with typical questions
aimed at cognitive restructuring or Cognitive Disputation (D) that
assists clients in evaluating the helpfulness of their beliefs and then
provides them with an opportunity for developing new Effective Beliefs
(E) that would then lead to more Functional Emotional or Behavioural
Reactions (F).
WHAT DOES CBT TARGET?
Almost all individuals who present for psychotherapy, present
with some sort of an emotional or behavioural problem. Even those individuals
who think that their greatest problem is a practical one (disciplining their
children/making a decision/dealing with difficult people) are typically
prevented from managing their practical dilemma as a result of their emotional
disturbance about it. One of the primary goals of CBT is thus to assist
individuals in reducing emotional distress, thereby experiencing more appropriate,
healthy emotional reactions. Those who seek 'happiness' continuously are
essentially misguided in the sense that positive emotions such as happiness,
joy or calmness, whilst pleasurable, are typically short-lived and unsustainable
for longer periods of time. CBT therapists prefer to consider emotional
reactions as either helpful and functional or unhelpful and dysfunctional.
The goal is to assist clients in shifting from unhelpful emotional states
to more appropriate, manageable ones.
As an example, many individuals who struggle with assertiveness are often
inhibited by intense guilt about the way in which others may feel in response
to their decisions. While having sensitivity to other's feelings is certainly
admirable and quite appropriate, feeling intense guilt about others' feelings
is often unhealthily inhibiting. In such a situation, one would typically
want to reduce the likelihood of feeling guilt and shift such an emotional
response to something more moderate and tolerable such as regret or disappointment.
Guilt in such a situation would typically be fueled by beliefs such as "I
must never do anything that others may not like" or that
"I am personally responsible for others feelings".
Regret on the other hand, would be based on more flexible, realistic beliefs
such as "while I'd prefer to always make decisions that others
are happy with, there is no rule that states that I have to always
place others satisfaction above my own and I am not personally responsible
for others' happiness". Such a shift in belief allows one to be
sensitive to others feelings, but not see their reactions as always
more important that what may be in ones own best interest. Such a restructuring
of one's thinking would thus help to reduce the presence of unnecessary
guilt and enable one to then act in a more assertive manner, thereby also
addressing the practical problem.
Below is a table of positive emotions, healthy negative emotions and unhealthy
negative emotions:
POSITIVE |
HEALTHY
NEGATIVE |
UNHEALTHY
NEGATIVE |
Calm |
Concern |
Clinical Anxiety |
Joy |
Sadness |
Depression |
Excitement |
Annoyance |
Clinical Anger |
Relief |
Regret / Remorse |
Guilt |
Euphoria |
Disappointment |
Shame |
Inspired |
Disappointment |
Hurt |
Simultaneously, behaviour may often also be targeted during intervention,
but this is often (but not always) secondary to the initial emotional goal.
Many behavioural interventions target specific behaviours without any initial
emotional goals. This would typically be the case with substance related
problems, procrastination, habit related disorders like tics, skin picking
or trichotillomania, and insomnia. Behavioural reactions associated with
depression or anxiety-related problems may often also be targeted directly,
with a change in one's emotional state being seen as secondary to this.
For instance, prolonged exposure to feared situations tends to result in
a decrease in anxiety and becoming more actively involved in pleasurable
activities tends to reduce feelings of depression.
IRRATIONAL OR DYSFUNCTIONAL
BELIEFS?
Cognitive restructuring is aimed at identifying those thoughts,
attitudes and assumptions that create, exacerbate or maintain intense, unhealthy
negative emotion such as severe anxiety or panic, shame, guilt, jealousy,
envy, intense anger, excessive shyness, and depression. Some of the cognitions
or thinking patterns associated with emotional disturbance may be automatic
and conscious and thus easily articulated; whilst others may be so well
rehearsed that they do not form part of conscious awareness. Once elicited
and identified, these beliefs are evaluated in a scientific manner with
regards to the following general principles:
- Whether they are merely subjective opinions or based on some sort
of objective evidence that suggests that they are more like facts than
mere opinions. In other words, are they in line with reality?
- Whether they help us to achieve our emotional or practical goals or
result in self-defeating emotional and behavioural reactions.
- Whether they follow logical reasoning.
Thoughts that (1) do not follow logical reasoning, (2) that represent
subjective opinion as oppose to being based on factual evidence and that
(3) are likely to lead to excessive emotional arousal or self-destructive
behaviour are considered dysfunctional, inaccurate or irrational. It is
these sorts of thinking errors or dysfunctional beliefs that are identified
and targeted throughout intervention. What we now know is that specific
sorts of cognitive errors are associated with specific emotional states
and behavioural responses. Well trained CBT therapists would often be
able to help their clients quickly identify which clinically relevant
beliefs are perpetuating their problem.
A variety of different dysfunctional beliefs have been identified and
conceptualized as contributing toward various forms of psychological distress.
Ellis, Beck and others have proposed somewhat different beliefs and belief
systems responsible for psychological disturbance. Beck typically considers
cognitive errors to be responsible for emotional distress and Cognitive
Therapy tends to focus mainly on the attributions or meanings that individuals
make about themselves, others or the world in response to specific situations
or stressors. Ellis' REBT model (Ellis & Harper, 1961) proposes that
four specific types of beliefs, otherwise known as evaluative beliefs,
underly psychological distress. These are further described below.
- Demands, result from our tendency to take healthy preferences or desires
and turn them into unrealistic, perfectionistic, rigid and absolute
rules and expectations of one's self, others or the world. Demandingness
is typically reflected in language which incorporates words such as
'must, ought to, should, have to and need'. A typical demand associated
with performance anxiety would be, "I absolutely must do well in
that exam and at the very least end up in the top three in my class".
- Awfulizing, which reflects an exaggeration of the badness or negative
consequences associated with a particular situation or event such that
a bad, inconvenient or uncomfortable situation is seen as terrible,
horrible or awful. For instance, "It would be terrible if I didn't
do well in my exam. It will be the end of my studies and I'll never
be able to achieve anything in my life".
- Low frustration tolerance (LFT) beliefs typically stem from demands
for ease and comfort, and reflect an intolerance of discomfort or frustration.
For example,"I would not be able to handle failing that test; I
couldn't stand the embarrassment. That, would be intolerable".
- Global evaluations of human worth, either of self or others, refer
to a set of beliefs that imply that our value and worth can be objectively
rated and that some people can be evaluated as objectively worthless
(including yourself) or at least less worthy than others. Typically,
individuals neglect merely judging their behaviour or performance (which
is objectively possible) and end up judging their entire selves instead.
For instance, "I would really be a complete failure and a worthless
idiot if I were to fail this test".
HOW TO FIND A CBT THERAPIST
There are unfortunately very few CBT therapists in South Africa. A
study by Möller and van Tonder (1999) suggested that only about
6% of South African clinical psychologists could be regarded as cognitive
behaviour therapists. As of the time of this study, only 20% of clinical
psychologists had had any training in CBT, only 5% used CBT more than
50% of the time, and only 4% regularly consulted CBT journals or literature.
As of 2011, no formal minimum training standards are provided for
CBT therapists in South Africa and there is no formal national CBT
organization or training standards committee. It may thus be most
helpful to consider psychotherapists as belonging to 1 of 4 categories
with respect to their proficiency and experience in using CBT:
(1) No experience or interest in the use of CBT as a therapeutic model.
(2) Some interest in and experience with the use of CBT.
(3) Primarily uses CBT as a therapeutic approach and has significant experience
in using CBT, has attended international conferences and workshops in CBT
but does not have any specific international certification as a CBT therapist.
(4) Internationally certified CBT therapists, with specific qualifications
based on supervised practice by an international training standards committee.
It is most probably wise, when seeking a therapist who provides CBT to
try and assess which of the above-mentioned categories they may fall into.
Many therapists will report that they use CBT, but few have actually had
specific supervised training in the model and many do not provide cutting
edge treatments for specific disorders. In addition, it would also be important
to check whether or not the therapist has specific experience in your area
of concern. For instance, an individual may have plenty of experience in
working with anxiety or depression, but little experience or expertise in
treating tic disorders, insomnia or psychosis, for example. Below is a list
of reasonable questions that one could ask a therapist prior to making an
appointment or during an initial appointment aimed at assessing their experience
with CBT.
QUESTIONS FOR DETERMINING A THERAPIST'S LEVEL OF EXPERTISE WITH CBT
Have you received any training in CBT?
Training could vary from an introduction during a Masters-program to an
internationally certified qualification.
Did your training include individual supervision of case material from
an experienced or internationally certified CBT therapist?
It is important to distinguish between theoretical training and practical
supervised training that includes individual supervision in the use of CBT
in working with clients.
Does your CBT training include international certification from an international
training standards committee?
Typical international certification is from the Beck Institute or the Albert
Ellis Institute. Other training centres in the USA and the UK also exist.
How many years experience do you have in practising CBT?
We all start with little experience and build our knowledge base. It would
be wise not to doubt a well trained and supervised CBT therapist with 1
or 2 years experience. It however goes without saying that those therapists
with greater practical experience, bring the expertise accumulated from
this experience to helping you.
In what way do you use CBT in your practice?
Many people will tell you that they integrate CBT into their practice. This
typically would entail using skills or techniques from more than one theoretical
orientation at the same time. This approach is known as eclecticism. This
is not unethical nor an unacceptable practice. Should you look for a CBT
therapist specifically, this is obviously not the type of service provided
by a therapist with an eclectic approach. Therapist will also tell you that
they use different theoretical approaches to treat different clients and
problems. This is also an acceptable approach, it would however be important
to determine if the therapist is sufficiently trained in CBT and if the
therapist would suggest CBT for your specific problem.
Ask if the therapist has training in the CBT treatment of your specific
disorder.
It important to know that the therapist has disorder specific training in
the condition that you require help with.
Ask the CBT therapist to explain the specific treatment to be employed
to treat your specific condition.
Inform yourself via recognised CBT websites about the newest treatments
available and the researchers responsible for the development of this treatment.
You will find a list of helpful links to international CBT training and
research facilities on our website (www.cognitive-behavioural-therapy.co.za).
MODERN-DAY CBT TREATMENT
OPTIONS
The theoretical contributions of the cognitive theorists
(Beck, Ellis etc.), together with the initial contributions of the behavioural
theorists (Pavlov, Skinner, Wolpe etc.) provided for the foundation of modern-day
CBT theory and practice. Modern-day CBT-based treatments for emotional and
behavioural disorders are however, continually being altered and revised.
These revisions are the product of what we are continually learning from research
about which factors are primarily responsible for the onset and maintenance
of psychological disorders. The recommended treatment guidelines for CBT-based
interventions with anxiety disorders, depression, borderline personality disorder,
insomnia, anger, substance use disorders, habit disorders and schizophrenia
have changed substantially over the last twenty and even the last ten years.
For instance, we now know that using controlled breathing and relaxation training
as a primary intervention strategy for panic disorder is not the most useful
way of tackling this highly treatable condition and may even reduce long-term
prognosis. We also now know that trying to reduce, suppress or remove negative
thoughts is less helpful than what we once thought when working with individuals
with depression. We know that how individuals react to their negative thoughts
and emotions is of greater importance than whether or not they have negative
thoughts or emotions in the context of anxiety or depression, for example.
There have been a number of more recent theoretical models that have gained
momentum over the course of the last decade, many of which are considered
as part of "the third wave" movement within the CBT tradition. Dialectical
Behaviour Therapy (DBT), Metacognitive Therapy (MCT) and Acceptance and Commitment
Therapy (ACT) would be typical examples thereof. Each of these "newer"
models within the CBT tradition emphasize the notion of non-judgmental acceptance,
awareness of and mindfulness toward negative thoughts and emotional states
as a means of reacting in a more functional manner toward these states. The
concept of mindfulness is regularly cited within modern-day CBT treatment
models and is often a significant treatment component that is introduced earlier
on in treatment but is not considered a means of treatment itself, in isolation.
Mindfulness is typically used as a means of emotional regulation and in reducing
emotionally driven behaviours that perpetuate emotional disturbance.
The table below provides a short summary of the most prominent treatment components
associated with modern-day CBT. These core treatment components would typically
be accompanied by standard treatment components such as psychoeducation, motivational
enhancement and relapse prevention.
DIAGNOSIS |
CBT
TREATMENT COMPONENTS |
PROMINENT
RESEARCHERS/ AUTHORS |
Panic Disorder |
Cognitive Restructuring,
Mindfulness, Interoceptive and Situational Exposure |
Barlow
Craske
Clarke |
PTSD |
Cognitive Restructuring, Prolonged
Imaginal and Situational (in vivo) Exposure |
Foa
Ehlers & Clark
Resick |
Social Phobia |
Cognitive Restructuring,
Mindfulness, Interoceptive and Situational Exposure |
Heimberg
Clarke and Wells
Hoffman, Albano |
Obsessive Compulsive
Disorder |
Cognitive Restructuring,
Mindfulness, Imaginal or Cognitive or Situational Exposure and Response
Prevention |
Foa, Abramowitz
Salkovskis, Rachman, Radomsky, Piacentini, Whittal
|
Phobias |
Cognitive Restructuring, Mindfulness,
Interoceptive and Prolonged Situational Exposure |
Ollendick and Ost |
Generalized Anxiety Disorder |
Cognitive Restructuring, Meta-cognitive
Therapy, Mindfulness, Imaginal/Cognitive Exposure, Situational (Uncertainty)
Exposure |
Wells, Dugas, Ladouceur, Borkovec |
Depression |
Cognitive Restructuring, Mindfulness,
Behavioural Activation, Behavioural Assignments |
Beck, Hollon, Freeman |
Insomnia |
Cognitive Restructuring, Sleep
Hygiene, Stimulus Control, Graded Sleep Restriction |
Edinger, Carney |
Tic Disorders |
Mindfulness, Awareness Training,
Habit Reversal, Cognitive Restructuring |
Woods, Piacentini |
Schizophrenia |
Activity Monitoring, Behavioural
Activation, Cognitive Restructuring, Behavioural Assignments/Evidence
Gathering |
Kingdon, Beck, Turkington, Grant |
Bipolar Mood Disorder |
Psychoeduction, Cognitive Restructuring
aimed at Enhancing Adjustment, Mood Awareness Training, Stimulus Control,
Cognitive Restructuring, Relapse Prevention |
Basco, Rush, Otto, Knauz |
Anger Related Problems |
Cognitive Restructuring, Mindfulness/Relaxation
Training, Situational Exposure |
Di Giuseppe, Tafrate, Kassinove |
Substance Related Disorders |
Cognitive Restructuring, Mindfulness,
Stimulus Control, Urge/Interoceptive and Situational Exposure, Contingency
Management, |
Carrol, Miller, Rollnick, Petry |
Compulsive Gambling |
Cognitive Restructuring, Mindfulness,
Stimulus Control, Urge Interoceptive and Situational Exposure, Contingency
Management |
Ladouceur |
Habit Disorders (Skin Picking,
Trichotillomania) |
Mindfulness, Stimulus Control,
Habit Reversal, Acceptance Practices |
Woods, Piancentini, Tolin, Franklin |
Borderline Personality Disorder |
Dialectical Behaviour Therapy,
Schema Therapy |
Linehan, Young |
ADHD (Adults) |
Behavioural Intervention aimed
at enhancing Organization and Planning, Reducing Distractibility, Reducing
Procrastination. Cognitive Restructuring |
Safren, Otto |
Anorexia Nervosa |
Behavioural Planning aimed at Weight
Gain, Systematic Exposure, Motivational Enhancement, Monitoring, Cognitive
Restructuring, |
Fairburn, Wilson, Agras |
Bulimia Nervosa |
Psychoeducation, Motivational Enhancement,
Monitoring, Stimulus Control, Cognitive Restructuring, Urge Tolerance
and Mindfulness |
Fairburn, Wilson, Agras |
Hypochondriasis |
Cognitive Restructuring, Mindfulness,
Imaginal/Cognitive Exposure/Situational (Uncertainty) Exposure and Response
Prevention, Interoceptive Exposure |
Salkovskis, Barsky |
|