Part science, part art
Reprinted from "CBT" issue of Visions Journal, 2009, 6 (1), p. 6
Cognitive-behavioural therapy (CBT) combines basic theories about how people learn (behaviourism) with theories about the way people think about and interpret events in their lives (cognition). CBT is now firmly established as the leading psychological treatment for many mental health conditions. Many research studies have demonstrated its effectiveness.1 Research shows that the skills people learn through CBT last long after the treatment ends.2
In CBT, the therapist and the client work together to identify unhelpful patterns of thinking and behaviour. For example, someone might only notice the negative things that happen to them and not notice the positive things. Or, someone might set unrealistic standards for themselves, such as “making mistakes at work is unacceptable.” It’s also important to identify unhelpful behaviours that maintain symptoms, such as avoiding certain situations and withdrawing from others.
The client and therapist also look at how thoughts and behaviours impact feelings. For example, if someone believes that nothing will work out for them in life, they may withdraw from others and avoid new opportunities. This, in turn, can lead to feelings of increased sadness, emptiness and anxiety. This is sometimes called a “vicious circle” of thoughts, feelings and behaviours.
Carefully constructed exercises are used to help clients evaluate and change their thoughts and behaviours. Some aspects of treatment focus more on thoughts and some aspects focus more on behaviours. If a client has difficulty identifying and challenging negative thoughts, the therapist might focus on addressing behaviours such as avoidance, withdrawal or poor social skills. On the other hand, if such behaviours are not as noticeable, the therapist may focus on challenging unrealistic thinking.
Common CBT interventions include:
setting realistic goals and learning how to solve problems (e.g., engaging in more social activities; learning how to be assertive)
learning how to manage stress and anxiety (e.g., learning relaxation techniques such as deep breathing, coping self-talk such as “I’ve done this before, just take deep breaths,” and distraction)
identifying situations that are often avoided and gradually approaching feared situations
identifying and engaging in enjoyable activities such as hobbies, social activities and exercise
identifying and challenging negative thoughts (e.g., “Things never work out for me”)
keeping track of feelings, thoughts and behaviours to become aware of symptoms and to make it easier to change thoughts and behaviours
CBT is most widely applied to mood disorders (such as depression) and anxiety disorders. It is also used to help people with substance use problems, personality disorders, eating disorders, sexual problems and psychosis. It is successfully delivered in individual, group and couples formats.
Applying CBT for depression and problem substance use
CBT for depression usually starts with education about depression and helping the client understand their symptoms as part of an illness that they can do something about.
Treatment strategies include helping clients to establish structure around daily activities, to become more aware of their mood and challenge negative thoughts, and to engage in pleasurable activities.
The therapist and client work together to challenge negative attitudes the client holds about the self, the world and the future, which may contribute to feelings of hopelessness.
John believed he was “no good” and a “failure” at work, in his romantic relationship and in his friendships. Over the years, he came to expect that bad things would happen and that things would always be difficult for him. This led him to give up on things quickly and believe that there was “no point in trying.” John’s therapist helped him identify these beliefs and look at the evidence for and against them. He was able to learn that he viewed the world in black and white, and started challenging himself to see the middle ground. John also learned to be more assertive and to do more activities that made him feel good about himself.
Substance use disorders
In the area of substance use, CBT was first used as a method to prevent relapse when treating problem drinking. It was later adapted to treat individuals who are addicted to nicotine, cocaine, marijuana and other drugs.
Cognitive-behavioural strategies for substance use disorders are based on the theory that learning processes, such as reinforcement and conditioning, play an important role in the development of addictive behaviours. People learn to identify and change problem behaviours by applying a range of different skills that can be used to reduce or stop drug use. Specific skills include:
exploring the positive and negative consequences of continued substance use
self-monitoring to recognize alcohol or drug cravings early on
identifying high-risk situations for substance use
developing strategies for coping with and avoiding high-risk situations and the desire to use
The therapist and client work together to anticipate problems and develop effective coping strategies.
Lynn has been struggling with problem drinking for several years. She knew there would be alcohol served at the upcoming company party. She also knew her co-workers sometimes drink too much and pressure her to drink. Lynn and her therapist developed a plan before the party. Lynn decided to avoid punch and only drink what she could measure, have soft drinks until she got a feel for the party, have no more than one alcoholic drink, stay no more than three hours and ask her boyfriend to pick her up.
Does CBT have limitations?
CBT has been criticized as being overly rigid and mechanistic, that is, focused mainly on an educational approach and setting goals. This may prevent an exploration of the big picture, which includes relationships, family of origin issues and emotions.
Also, relatively little is known about the process of matching treatments (including CBT) to individual people. Skilled practitioners, though, are generally able to adapt CBT to a wide variety of people and circumstances.
CBT is not the best approach for all clients, however. Individuals who have a more chronic or recurring illness may need repeated interventions. Or they may need a shift to approaches other than CBT to address early life experiences as well as personality, interpersonal and identity issues. And given that
CBT is quite structured and tends to focus on thinking rather than emotions, it may not be the best therapy for people who have strong and immediate emotional reactions. More generally, when a client feels very emotional, a focus on cognition and behaviour is less effective for change.
Although CBT has been used with children as young as seven to nine years old, it’s most effective with children over 14. At this age, children have more fully developed cognitive skills. Younger children, or teens and adults with cognitive disabilities, usually respond best to behavioural strategies and structuring of the environment rather than a focus on thinking.
The development of cultural adaptations to CBT is still in the beginning stages. CBT is largely based on the values supported by the dominant culture. In North America, these values include assertiveness, personal independence, verbal ability, logic and behaviour change. But specific manuals have been developed for adapting CBT to Chinese Americans and Haitian American adolescents.3-4 *
CBT should not be applied as a ‘cookie-cutter’ approach. The therapist must carefully assess the client’s motivations and how to best approach him or her. Otherwise, the client may resist the treatment if they don’t accept the model or don’t feel the therapist is listening to them.
Clearly, a skilled practitioner must apply CBT within a good working relationship with the client. This is the art, as opposed to the science, of therapy.
About the author
Michelle is an Adjunct Professor and clinical psychologist working at the Centre for Applied Research in Mental Health and Addiction (CARMHA) at Simon Fraser University.
Somers, J.M. (2007). Cognitive behavioural therapy (CBT): Core information document. Vancouver: Centre for Applied Research in Mental Health and Addiction, Simon Fraser University. www.carmha.ca/publications/index.cfm?contentID=26.
Hawton, K., Salkovskis, P., Kirk, J. et al. (1989). Cognitive behaviour therapy for psychiatric problems: A practical guide. London: Oxford Press.
Hwang, W. (2009). The formative method for adapting psychotherapy (FMAP): A community-based developmental approach to culturally adapting therapy. Professional Psychology: Research and Practice, 40(4), 369-377.
Nicolas, G., Arntz, D., Hirsch, B. et al. (2009). Cultural adaptation of a group treatment for Haitian American adolescents. Professional Psychology: Research and Practice, 40(4), 378-384.