CBT is very different to the other therapies covered in this book, so this chapter is also going to be different. Like the therapy itself it will have lots of structure and lots of lists. CBT emphasizes thinking and thoughts. The underlying premise is that ‘faulty’ thinking gives rise to anxiety and depression rather than the other way round. CBT is the product of bringing together the strengths of behaviour therapy and those of cognitive therapy.
Behaviour therapy is exactly what the name implies. It was a radical departure from psychoanalysis with its emphasis on unconscious motivation and symbolization, and it simply tried to help the patient alter their behaviour. It is ultimately derived from the work of the Russian psychologist Pavlov and his experiments with his dogs. Pavlov discovered how behaviours could be ‘conditioned’ by associating them with stimuli, such as making his dogs salivate at the sound of a bell after getting them used to the bell being rung before food was delivered (see ).
The most famous (or perhaps infamous) exponent of this learning theory was B. F. Skinner, who believed that all behaviours were learned by this process of association. Skinner invented a special cage for rats which became known as a ‘Skinner box’. In this they were either rewarded with food or punished with electrical shocks when they performed specific actions, and they demonstrated remarkably quick learning. His conclusion was that any behaviour, whether in a rat or a human, could be trained by ‘reinforcing’ it with positive stimuli (rewards), or extinguished by associating it with negative stimuli (an unpleasant taste, a small electric shock). In clinical practice relaxation was most often used as the positive stimulus to enable patients to confront feared situations, usually in a stepwise manner. Behaviour therapy is particularly successful in phobias (simple phobias such as fear of spiders and also in more complex phobias such as agoraphobia) and in sexual therapies. ‘Aversive’ behaviour therapy, where unwelcome behaviours are associated with unpleasant stimuli (e.g. alcohol with a nausea-inducing drug), has been less influential.
Behaviour therapies are nowadays more likely to be considered as a routine treatment rather than as a psychotherapy. It is a fine distinction and one can argue both ways. However, they do generally lack the specific, highly personal relationships we associate with psychotherapy, so will not be dealt with in any detail in this book. However, that is not to dismiss them. They still play an important role in child psychiatry and in some services for individuals with learning disabilities.
Cognitive therapy was developed in the 1960s by Aaron Beck in America. He was struggling to help some of his patients who did not respond well to his analysis. They appeared to value self-mastery much more than self-understanding: control of their symptoms rather than understanding or insight. ‘Cognition’ is usually defined as the mental process of acquiring knowledge and understanding through thought, experience, and the senses. The focus in cognitive therapy is therefore on our patterns of thinking and ‘knowing’ things, which is often based on unquestioned assumptions. Beck’s change of focus provided a radical shift, which eventually led to the development of CBT.
The underlying philosophy of CBT was propounded by the Ancient Greek philosophers, the Stoics. They believed that happiness depends not on what happens to us but on what we make of it. We call a Stoic someone who seems able to shrug off life’s misfortunes and still remain contented and productive. So CBT does not dwell on the difficulties of your childhood or subsequent traumas, but on what you have made of them and how you are coping now. It focuses on the present. It insists that you are in charge and can make choices, and it is overwhelmingly interested in what you think.
CBT therapists are not naïve about this focus on thinking. They know that thinking, feeling, and behaviour (indeed even physical health) are all interconnected and continually influence each other. There are constant feedback loops between them. However, CBT emphasizes how thinking drives emotions, and it selects thinking as the point in the system where change can most effectively be achieved. Sessions are consequently very different from most other therapies, but before describing that practice it helps to understand some of the theory.
Here comes the first list of three. CBT theory identifies three layers of thinking to address (see ). The first is negative automatic thoughts, below this our underlying assumptions, and then at the very fundamental level our core beliefs often called schemas. Most CBT will concentrate on negative automatic thoughts and only dive deeper during more complex and protracted therapies.
We are continually making judgements about what is going on around us. We know from cognitive neuroscience that the vast majority of these judgements are instantaneous and unconscious. We respond accurately to our environment without being aware of the cues we receive, or of the assumptions about them that condition our responses. In a crowded bar we move away from someone staggering without even noticing we are doing it, never mind being aware of why. We have registered subconsciously that they may be drunk, and we know from long experience to be wary of intoxicated people. We make such judgements and assumptions all the time, instantaneously, without being aware of them. We have to, there are too many to be made. Were we to consider them all consciously we would be completely paralysed by indecision.
When we are stressed our assumptions can become more rigid and negative—we easily assume the worst. We are unaware of this happening but it affects what we do, and soon also how we feel, so we may become anxious or depressed and not be sure why. We are unaware of how such automatic thoughts can cause and maintain anxiety and depression.
CBT aims to help us identify and then challenge these negative automatic thoughts. The processes used are called Socratic questioning and collaborative empiricism. Essentially it starts with a simple question: ‘What is going through your mind right now?’ Clarifying and challenging thoughts, collaborative empiricism, involves three further questions:
These assumptions shape the way we understand how the world works. They are the maxims, or principles, we apply in managing our everyday lives. They state a consequence to an action, which we believe to be inevitable. ‘If I do this then this will happen.’ ‘I should do this because … ’ ‘Unless I do this then … ’ ‘I must do this or … ’ These assumptions underlie the negative automatic thoughts, and Beck highlighted three that he regularly encountered:
I am nothing unless I am loved—acceptance
I am what I accomplish—competence
I cannot ask for help—control
These are the fundamental beliefs we hold about ourselves, which shape who we feel we are. They are often paired so that for each important belief we also hold its mirror opposite in balance. When stressed we all too easily lose sight of our positive self-belief and focus on its opposite. A successful professional may for example usually think of herself as hard working and reliable. However, under pressure she switches to believing she is a fraud who gets by on the absolute minimum and will be found out. We don’t have core beliefs about every tiny detail of our lives, only those aspects that are important to us. Again there is a CBT rule of three (see ).
Only in very protracted (schema-based) CBT are core beliefs addressed directly. Therapists usually rely on the work on negative automatic thoughts to influence negative core beliefs.
The immediately striking thing about CBT is that it is short, sometimes very short. Beck recommended between four and fourteen weekly sessions for anxiety states, although most therapies hover between six and twenty sessions. You also usually know exactly how long it is going to take right from the start. Many services are very strict about how many sessions are offered. The IAPT service (see ) offers four to six sessions.
CBT is very structured and pretty prescriptive. Therapists are taught in great detail about its specific procedures and individual components. They may even use a manual outlining them, sometimes giving the order in which they should be applied. CBT therapists consider this open and transparent approach to be an important strength of their model. There is no mystique, and patients are encouraged to read up about the various practices. Being well-informed improves collaboration and reduces misunderstandings.
Socrates was a Greek philosopher whose teaching consisted of asking questions (see ). He believed that we already know the answers we seek but need help in finding them. This process came to be known as Socratic dialogue. You are the one who has the automatic thoughts and only you can identify them (think back to Carl Rogers’ client-centred approach in ).
The therapist’s function is to help you do this using careful questioning. She will insist on clarity, especially in distinguishing thinking from feeling. It is remarkable how often we say ‘I feel’ when we mean ‘I think’. If we say ‘I feel that the banking crisis is now resolving’ we hardly register that what we mean is we think the banking crisis is now resolving. We may also have feelings about it, perhaps relief or anger that it was allowed to happen, but that is a different matter from our thoughts.
There are many techniques for identifying and clarifying automatic thoughts. Insisting that patients answer with statements rather than hypotheses is important in the early stages:
THERAPIST: What were you thinking just then?
CLIENT: It was probably something about how my wife would react to my leaving my job.
THERAPIST: That’s a speculation about what you might have been thinking, what was the exact thought?
CLIENT: OK, I thought she would consider me stupid and impulsive.
Asking patients to describe the worst potential outcomes from their current train of thought is also used:
What’s the worst thing you think would happen if your wife thought you were being impulsive? Do you think she would despise you or perhaps even leave you?
Getting patients to recall distressing recent events (imagery) also sharpens awareness of the associated thoughts. Sometimes the therapist may be fairly sure what the patient is thinking, because they have come across it in many previous patients. In CBT the therapist can suggest this as a possibility (although not a certainty)—something that other therapists might be very reluctant to do.
Once negative automatic thoughts have been identified they need to be tested and examined. This is referred to as collaborative empiricism. It is called empirical because it tests ideas in practice rather than in theory, and collaborative because therapist and patient do it together. For example, a patient reports a setback: ‘It was disastrous, a hopelessly public screw-up. Nobody will ever take my opinions seriously again.’ The therapist encourages him to think through the evidence for and against this belief. She may ask him to give examples of when his opinion has been ignored and when it has not. The patient is encouraged to find examples of how people have recently followed his advice and taken him seriously. Collecting such evidence can demonstrate that the negative automatic thought is grossly exaggerated, if not downright wrong. Catastrophizing is a common feature in automatic thinking. There may indeed have been a price paid for some mistake, but it does not mean everything is lost, despite how it may feel. Introducing shades of grey into such black-and-white thinking characterizes collaborative empiricism.
The distinction between identifying and testing automatic thoughts can be less clear in practice. An example is getting patients to think through the pros and cons of individual thoughts and defining the terms they use more clearly. Doing this both refines and simultaneously tests these thoughts. Patients often apply more severe standards to their own behaviour than to that of others. This can be exposed by asking them to apply what they have just said about themselves to others: ‘Would you judge your wife that way?’ ‘Would you bring up your children to believe that?’
In all CBT exercises thoughts are treated as hypotheses to be tested, not incontrovertible facts. Testing them in the session can demonstrate this, but the most powerful test is to try them out in reality. Such behavioural experiments are part and parcel of CBT. They will be considered more in the next section about homework, which is where they are usually conducted.
Collaborative empiricism has two functions. The first, and most obvious, is to identify, test, and modify negative automatic thoughts. The second is to teach the patient to become his own therapist. The process of questioning matters as much as the answers. Learning to recognize and test dysfunctional thoughts and internalizing this process is held to be responsible for CBT’s long-term effects. You are no longer a passive victim of your thinking.
With so few sessions it is important to make every one count. In dynamic psychotherapy holding on to an emotion or thought until the next session can be important learning in itself, but CBT therapists don’t want patients to keep things on hold for a week. They want them to work on what they are learning, to practise and test it out between sessions. Therapists encourage clients to keep putting into practice what they learn in sessions and so devise homework tasks. The end of each session is used to review what has been learned and to plan together how to practise it before the next session. Most homework consists of deliberately trying out feared actions to learn their real consequences, but there is a whole range of possible tasks.
Many cognitive homework tasks are things you can do alone. One is simply to read and learn more about your problems and the possible treatments. CBT therapists strongly encourage self-education and may suggest chapters from specific books, especially CBT self-help books. Another is writing, usually writing a daily thought record. This records the occurrence of negative automatic thoughts, noting their context and perhaps how you challenged them. Listening again to tape-recorded sessions is particularly useful, as it isn’t always easy to take in everything during a session. Remembering upsetting events in great detail, visualizing them happening (imagery), can feed back into the next session. Listening to recorded sessions or writing down your thoughts also helps get over the shyness of early psychotherapy.
Behavioural homework is generally the more powerful challenge. After all, this is real empiricism—testing out what happens in the real world, not in your imagination. Behavioural experiments test out individual automatic thoughts. Imagine you have identified a powerful negative automatic thought during a session: ‘Any doubt I express indicates incompetence and people at work will despise me.’ You then find some situations at work to practise saying ‘I’m really not sure what is best here’, and observe (and then write down) what the response is. Most likely it is something like: ‘Yes, I know, it is a tricky one. I’m never entirely sure myself.’ This experience is much more powerful than just imagining it. Often one has to work up to such experiments one step at a time. Confidence improves with each success. Activity scheduling in depression can act in the same way, as completing small, defined tasks chips away at the belief that they ‘can’t do anything at all’.
CBT homework is agreed between patient and therapist. It is not like school where the teacher sets the same homework for the whole class. CBT homework, especially behavioural experiments, has to be very specific. It must cover the where, when, and how, not just the what. It is specific to the issues under examination and is negotiated and usually written down. Often the tasks are practised in the session: ‘OK, we have agreed on what you are going to say at work, try it out on me first.’ The homework experiences are reviewed in the following session.
So far we have focused on the content of CBT sessions, but CBT has a well-developed structure which is also important for its success. CBT therapists always start with a careful formulation of your problems in the assessment session. As with everything else in CBT there is nothing secret about it and your therapist will share it with you. Because CBT is brief, the formulation must include an agreement on what will be worked on. The formulation takes account of the past, but in shorter, simpler CBT therapies past experiences take a back seat to what is going on now. In more extensive therapies for complex problems understanding the past may be crucial to properly understanding current concerns, and the formulation will take account of this. If there are more problems than can be addressed in the time available, the formulation will prioritize them.
Individual sessions are also structured. They start with a review of the previous session and any homework. An agenda is set for the session, agreeing what will be worked on. Towards the end of the session what has gone on will be reviewed and summarized. Homework for the upcoming week will be negotiated and agreed. All this sounds businesslike and very hard work, but as with all therapies the CBT therapist is closely attuned to how the patient is feeling. Also, as with everything in CBT, these are joint decisions and not simply imposed on you.
All therapies aim to bring lasting change. CBT helps you to learn the techniques that make you your own therapist, so that you can continue practising what you have learned. Having one or more ‘booster’ sessions after the therapy ends is common, sometimes the final sessions are spaced out with longer intervals between them. Negative thoughts are not abolished by CBT—we all have them. However, CBT should make you much better at dealing with them. Some falling off of improvements is inevitable after almost any therapy, and CBT therapists warn patients that it will happen. A review session between a month and three months after finishing can serve to re-energize and fine tune the self-therapy. It also helps make the point that the work goes on long after the therapy ends.
CBT therapists rely heavily on measurement. They use questionnaires in their work to measure symptoms and track changes. These include scales for specific disorders (obsessive compulsive disorder, eating disorders, etc.), but anxiety and depression ratings are the ones most widely used. Scales are generally completed at the start and again at the end of therapy, to assess the outcome, but sometimes they are used to track changes during treatment. Filling out such questionnaires is more often a useful exercise in itself, training the patients to make judgements about degrees rather than catastrophize.
CBT has been notable among the psychotherapies in its wholehearted embrace of rigorous scientific testing of its effects. This follows logically from its approach. Just as the therapy tests the real effects of negative thoughts, so practitioners want to test the real effects of the treatment. CBT is the most scientifically investigated psychotherapy, with literally dozens of careful studies. Specific modifications for different disorders have also been tested, including CBT for eating disorders, for different anxiety disorders, personality difficulties, and sexual disorders.
CBT’s engagement with research reflects its underlying empirical approach, but is also due to mainly being championed by clinical psychologists who have a very scientific training. One result is that in many publicly funded services it may be the only psychotherapy available. This is a pity, and doubly so. First because the evidence for non-CBT therapies does suggest that they are also effective, although there are far fewer studies. Second, it is a pity because CBT does not suit everyone, nor does it always work. No therapy suits everyone. Drop out rates are quite high in CBT, so where are these patients to look for further help? CBT’s overwhelming lead in research is somewhat demoralizing for non-CBT therapists. However, failing to conduct research is not really a long-term option in our modern, evidence-based world.
Because the different components in CBT practice are so well described, they can be mixed and matched to different clinical needs and can be ‘branded’ for them. This can involve relatively minor, but highly effective, changes in practice such as that developed for eating disorders. CBT-E as it is called (the E stands for enhanced, not eating) is used with patients suffering from both anorexia nervosa and bulimia. It lasts for twenty sessions, forty for underweight patients, and requires from the outset that the patient tries to eat regularly and that they be weighed at each session. It downplays the examination of automatic thoughts, focusing more on the responses to change in behaviour and weight. Neither the dietary diary nor taped sessions are used, as they have been found to encourage unhealthy rumination. This is an example of CBT adapted and shaped to a specific clinical problem, rather than a major departure in practice.
Mindfulness-based cognitive therapy (MBCT) and dialectical behaviour therapy (DBT) go well beyond adaptation and add a range of novel practices. While DBT is a very specialized and restricted treatment, MBCT is increasingly widespread and popular. It has been shown to be particularly effective in reducing the risk of further relapses in people who have had several episodes of depression.
Mindfulness draws on Buddhist ideas of ‘being in the moment’ and the practice of meditation. Patients reduce the impact of negative thoughts by developing metacognition—being able to create a distance from which to think about their thinking. In practice this means recognizing a negative automatic thought as just that: a thought that one has which one can either accept or reject. There is no obligation to respond to it, it is enough simply to note it. Using mindfulness techniques of being in the moment, devoid of past and future, produces a more serene, non-judgemental state. Mindfulness training consists of eight weekly two-hour classes, with a one-day event halfway through. It prescribes guided meditation for extended periods between sessions and developing a mindfulness approach in all aspects of daily life.
DBT, although it includes mindfulness practices, is almost the polar opposite in tone. It was developed for very troubled people whose lives were in chaos and who often self-harmed. It is very intensive and quite forceful. Weekly individual CBT sessions target reducing self-harm and developing skills to minimize risk and stress. It is called ‘dialectical’ because it has two competing elements, mindfulness versus confrontation. The latter involves learning how to regulate powerful feelings and tolerate distress.
CBT has a very different feel and a different ethos to the other psychotherapy and counselling approaches we have covered so far. It is much more structured and predictable. Some patients react against what they experience as a rather mechanical quality, far removed from explorations of personal narrative and sense of self. Others, however, welcome this clarity and structure. Longer and more complex CBT treatments often concern themselves with relationships and blur the sharp distinctions from more dynamic approaches, particularly when applied by more senior practitioners. Be that as it may, CBT is a radical departure which has changed the face of psychotherapy. It is still a relatively young, vigorous, and expanding innovation, and a Very Short Introduction devoted entirely to the subject is soon to be published. It will be fascinating to see how CBT looks in ten to fifteen years’ time.