What to Expect from Cognitive Behavioral Therapies
There are many different forms of cognitive and behavioral therapies (CBT), and CBT approaches can be used to treat a broad range of disorders, including mood and anxiety disorders, eating disorders, relationship problems, difficulties with anger and emotion regulation, personality disorders, and even substance abuse and psychotic disorders. The basic premise underlying CBT, whether it is conducted with an individual, family, couple or in a group, is that thoughts, feelings and behaviors are inter-related, so altering one can help to alleviate difficulties in another. For instance, changing negative thoughts about oneself can lead to less sadness and anxiety, and more willingness to try new activities and work on improving relationships.
Defining Features of CBT
Therapy tends to be time-limited, so a client and therapist may decide to work together for a few months, and then plan to evaluate their progress. This does not mean that treatment cannot continue after this time, but specific goals are set for each phase of therapy with the intent that a client's ultimate goal is to become his or her own therapist and not remain in therapy long-term.
Treatment focuses on trying to resolve current problems. The client's past is not ignored and early learning experiences are considered important in CBT models; however, the main focus is on helping to reduce the distress and related symptoms that are impairing a person's current functioning.
CBT models do not assume a single cause for a given problem, or assume that identifying the cause of a problem is necessary for treatment to be successful. It is recognized that family background, genetic and biochemical vulnerabilities, as well as numerous individual and social factors likely all play a role in the development of a disorder, but the primary interest is in determining those factors that are currently maintaining the problem.
CBT can be conducted with or without medication, but the decision to start or stop medication needs to be carefully considered to insure that medication will help rather than interfere with the therapy work.
There is a strong scientific research base supporting the effectiveness of CBT for many problem areas, and the emphasis on selecting approaches that have been tested is a hallmark of CBT. Along these lines, the therapy itself incorporates a scientific perspective. The therapist and client follow a 'collaborative empiricism' approach, which means that ideas are treated as hypotheses that can be tested. The client is frequently encouraged to gather evidence to determine what works best for him or her, and to check the actual consequences of maintaining versus changing old thinking and behavior patterns.
What Happens During and Between Therapy Sessions?
Therapy sessions tend to be relatively structured, meaning that an agenda is set to make sure that certain material is covered in each session. There is, of course, flexibility regarding the content and format of sessions and the agenda is set collaboratively by the client and therapist. However, most sessions will involve some discussion of current mood and difficulties, a review of homework and progress on the work from the prior session, learning a new skill or discussion of a particular issue, and setting a plan for work to be completed before the next session.
Homework is a key component of CBT. The goal of therapy is to teach clients new skills to more effectively manage their difficulties, so much of the work happens outside of sessions as clients try to practice these skills in their day-to-day life. Homework is usually very practical, and involves trying out new behaviors, thinking strategies, etc., rather than the kind of homework associated with classroom learning. There are no tests in CBT!
Consistent with the scientific approach that characterizes CBT, the client and therapist gather 'data' to learn about the client's problems and potential solutions. Assessment is common in CBT and may involve completing questionnaires to see how symptoms are changing over the course of treatment, or completing self-monitoring exercises to gather information that might help guide the treatment plan. Examples of self-monitoring exercises include tracking changes in mood, self-critical thoughts, or unhealthy behaviors, such as bingeing in eating disorders. These 'data' are not used to judge the client, but to better target the therapy for the individual and monitor progress.
Common Treatment Strategies
There are numerous techniques used in CBT, so the list below is by no means exhaustive. Depending on the needs of the particular client, therapy is likely to involve some of the following:
Responses to unhealthy thinking:
- 'Cognitive restructuring' involves trying to re-evaluate the negative thinking patterns that maintain distorted beliefs about oneself, the world, and relating to others. For instance, a person with social phobia could be taught to challenge his or her assumption that social rejection is inevitable.
- Strategies to promote more effective problem solving and decision making are emphasized.
- 'Mindfulness' techniques help clients gain some distance from their negative thinking so they can recognize that thoughts do not have to determine behaviors.
Responses to unhealthy behaviors:
- Clients are taught how to gradually start to re-enter situations they have been avoiding (e.g., because of fear in anxiety disorders, or low motivation in depression). This is not done in a coercive way; instead, clients learn how to gain a sense of control and predictability in situations that previously seemed overwhelming.
- Activities that provide a sense of pleasure or mastery are planned to promote a more enjoyable and fulfilling life.
- Training in new skills may be provided, such as how to communicate more effectively, be assertive, or enhance social interactions.
Responses to painful feelings:
- Clients are sometimes taught how to work on accepting or tolerating painful emotions, and sometimes taught how to try to change those emotions in the moment.
- Relaxation exercises are often included to help reduce overall stress.
- Strategies to manage extreme emotional reactions are taught, such as ways to deal with intense anger or urges to harm oneself.
Clark, D.M. & Fairburn, C.G. (1996, Editors). Science and practice of cognitive behaviour therapy. New York: Oxford University Press.
Dobson, K. (2002, Editor). Handbook of cognitive-behavioral therapies, Second edition. New York: Guilford Press.
Greenberger, D., & Padesky, C.A. (1995). Mind over mood: Change how you feel by changing the way you think. New York: Guilford Press.