Cognitive Behavioural Therapy

This leaflet is for anyone who wants to know more about Cognitive Behavioural Therapy (CBT). It discusses how it works, why it is used, its effects, its side-effects, and alternative treatments. If you can't find what you want here, there are sources of further information at the end of this leaflet.

What is CBT?

It is a way of talking about:

• how you think about yourself, the world and other people
• how what you do affects your thoughts and feelings.

CBT can help you to change how you think ('Cognitive') and what you do ('Behaviour'). These changes can help you to feel better. Unlike some of the other talking treatments, it focuses on the 'here and now' problems and difficulties. Instead of focusing on the causes of your distress or symptoms in the past, it looks for ways to improve your state of mind now.

When does CBT help?

CBT has been shown to help with many different types of problems. These include: anxiety, depression, panic, phobias (including agoraphobia and social phobia), stress, bulimia, obsessive compulsive disorder, post-traumatic stress disorder, bipolar disorder and psychosis. CBT may also help if you have difficulties with anger, a low opinion of yourself or physical health problems, like pain or fatigue.

How does it work?

CBT can help you to make sense of overwhelming problems by breaking them down into smaller parts. This makes it easier to see how they are connected and how they affect you. These parts are:

• A Situation - a problem, event or difficult situation. From this can follow:
• Thoughts
• Emotions
• Physical feelings
• Actions

Each of these areas can affect the others. How you think about a problem can affect how you feel physically and emotionally.

All these areas of life can connect like this: 5 Areas

What happens in one of these areas can affect all the others.

There are helpful and unhelpful ways of reacting to most situations, depending on how you think about it. The way you think can be helpful - or unhelpful.

An example:

The Situation

You've had a bad day, feel fed up, so go out shopping. As you walk down the road, someone you know walks by and, apparently, ignores you. This starts a cascade of:

	Unhelpful	Helpful
Thoughts:	He/she ignored me - they don't like me	He/she looks a bit wrapped up in themselves - I wonder if there's something wrong?
Emotional: Feelings	Low, sad and rejected	Concerned for the other person, positive
Physical:	Stomach cramps, low energy, feel sick	None - feel comfortable
Action:	Go home and avoid them	Get in touch to make sure they're OK

The same situation has led to two very different results, depending on how you thought about the situation.

How you think has affected how you felt and what you did. In the example in the left hand column, you've jumped to a conclusion without very much evidence for it - and this matters, because it's led to:

• having a number of uncomfortable feelings
• behaving in a way that makes you feel worse.

If you go home feeling depressed, you'll probably brood on what has happened and feel worse. If you get in touch with the other person, there's a good chance you'll feel better about yourself.

If you avoid the other person, you won't be able to correct any misunderstandings about what they think of you - and you will probably feel worse.

This 'vicious circle' can make you feel worse. It can even create new situations that make you feel worse. You can start to believe quite unrealistic (and unpleasant) things about yourself. This happens because, when we are distressed, we are more likely to jump to conclusions and to interpret things in extreme and unhelpful ways.

CBT can help you to break this vicious circle of altered thinking, feelings and behaviour. When you see the parts of the sequence clearly, you can change them - and so change the way you feel. CBT aims to get you to a point where you can 'do it yourself', and work out your own ways of tackling these problems.

What does CBT involve?

The sessions
You can do CBT individually or with a group of people, or even a self-help book or computer programme.

In England and Wales, two computer-based programmes have been approved for use by the NHS. Fear Fighter is for people with phobias or panic attacks; Beating the Blues is for people with mild to moderate depression.

If you have individual therapy:

• You will usually meet with a therapist for between 5 and 20, weekly, or fortnightly sessions. Each session will last between 30 and 60 minutes.
• In the first 2-4 sessions, the therapist will check that you can use this sort of treatment and you will check that you feel comfortable with it.
• The therapist will also ask you questions about your past life and background. Although CBT concentrates on the here and now, at times you may need to talk about the past to understand how it is affecting you now.
• You decide what you want to deal with in the short, medium and long term.
• You and the therapist will usually start by agreeing on what to discuss that day.

The work

• With the therapist, you break each problem down into its separate parts, as in the example above. To help this process, your therapist may ask you to keep a diary. This will help you to identify your individual patterns of thoughts, emotions, bodily feelings and actions.
• Together you will look at your thoughts, feelings and behaviours to work out:
• if they are unrealistic or unhelpful
•  how they affect each other, and you.
• The therapist will then help you to work out how to change unhelpful thoughts and behaviours.
• It's easy to talk about doing something, much harder to actually do it. So, after you have identified what you can change, your therapist will recommend 'homework' - you practise these changes in your everyday life. Depending on the situation, you might start to:

• question a self-critical or upsetting thought and replace it with a more helpful (and more realistic) one that you have developed in CBT

• recognise that you are about to do something that will make you feel worse and, instead, do something more helpful.

• At each meeting you discuss how you've got on since the last session. Your therapist can help with suggestions if any of the tasks seem too hard or don't seem to be helping.
• They will not ask you to do things you don't want to do - you decide the pace of the treatment and what you will and won't try. The strength of CBT is that you can continue to practise and develop your skills even after the sessions have finished. This makes it less likely that your symptoms or problems will return.

How effective is CBT?

• It is one of the most effective treatments for conditions where anxiety or depression is the main problem.
• It is the most effective psychological treatment for moderate and severe depression.
• It is as effective as antidepressants for many types of depression.

Behavioral Therapy

Behaviorism see psychological disorders as the result of maladaptive learning, as people are born tabula rasa (a blank slate). They do not assume that sets of symptoms reflect single underlying causes.

Behaviorism assumes that all behavior is learnt from the environment and symptoms are acquired through classical conditioning and operant conditioning.

Classical conditioning involves learning by association and is usually the cause of most phobias. Operant conditioning involves learning by reinforcement (e.g. rewards) and punishment, and can explain abnormal behavior should as eating disorders.

Consequently, if a behavior is learnt, it can also be unlearned.

Therapies

Behavioral therapies are based on the theory of classical conditioning.  The premise is that all behavior is learned; faulty learning (i.e. conditioning) is the cause of abnormal behavior. Therefore the individual has to learn the correct or acceptable behavior.

An important feature of behavioral therapy is its focus on current problems and behavior, and on attempts to remove behavior the patient finds troublesome. This contrasts greatly with psychodynamic therapy (re: Freud), where the focus is much more on trying to uncover unresolved conflicts from childhood (i.e. the cause of abnormal behavior).  Examples of behavior therapy include:

o          Systematic Desensitization

o          Aversion Therapy

o          Flooding

The theory of classical conditioning suggests a response is learned and repeated through immediate association.  behavioral therapies based on classical conditioning aim to break the association between stimulus and undesired response (e.g. phobia, additional etc.).

Aversion Therapy

Aversion therapy is used when there are stimulus situations and associated behavior patterns that are attractive to the client, but which the therapist and the client both regard as undesirable. For example, alcoholics enjoy going to pubs and consuming large amounts of alcohol

Aversion therapy involves associating such stimuli and behavior with a very unpleasant unconditioned stimulus, such as an electric shock.

The client thus learns to associate the undesirable behavior with the electric shock, and a link is formed between the undesirable behavior and the reflex response to an electric shock.

In the case of alcoholism, what is often done is to require the client to take a sip of alcohol while under the effect of a nausea-inducing drug.  Sipping the drink is followed almost at once by vomiting. In future the smell of alcohol produces a memory of vomiting and should stop the patient wanting a drink.

More controversially, aversion therapy has been used to "cure" homosexuals by electrocuting them if they become aroused to specific stimuli.

Critical Evaluation

Apart from ethical considerations, there are two other issues relating to the use of aversion therapy.

First, it is not very clear how the shocks or drugs have their effects.  It may be that they make the previously attractive stimulus (e.g. sight/smell/taste of alcohol) aversive, or it may be that they inhibit (i.e. reduce) the behavior of drinking.

Second, there are doubts about the long-term effectiveness of aversion therapy.  It can have dramatic effects in the therapist’s office.  However, it is often much less effective in the outside world, where no nausea-inducing drug has been taken and it is obvious that no shocks will be given.

Also, relapse rates are very high – the success of the therapy depends of whether the patient can avoid the stimulus they have been conditioned against.

Flooding

Flooding (also known as implosion therapy) works by exposing the patient directly to their worst fears. (S)he is thrown in at the deep end. For example a claustrophobic will be locked in a closet for 4 hours or an individual with a fear of flying will be sent up in a light aircraft.

What flooding aims to do is expose the sufferer to the phobic object or situation for an extended period of time in a safe and controlled environment. Unlike systematic desensitisation which might use in vitro or virtual exposure, flooding generally involves vivo exposure.

Fear is a time limited response. At first the person is in a state of extreme anxiety, perhaps even panic, but eventually exhaustion sets in and the anxiety level begins to go down. Of course normally the person would do everything they can to avoid such a situation. Now they have no choice but confront their fears and when the panic subsides and they find they have come to no harm. The fear (which to a large degree was anticipatory) is extinguished.

Prolonged intense exposure eventually creates a new association between the feared object and something positive (e.g. a sense of calm and lack of anxiety). It also prevents reinforcement of phobia through escape or avoidance behaviours.

Critical Evaluation

Flooding is rarely used and if you are not careful it can be dangerous. It is not an appropriate treatment for every phobia. It should be used with caution as some people can actually increase their fear after therapy, and it is not possible to predict when this will occur. Wolpe (1969) reported the case of a client whose anxiety intensified to such as degree that flooding therapy resulted in her being hospitalized.

Also, some people will not be able to tolerate the high levels of anxiety induced by the therapy, and are therefore at risk of exiting the therapy before they are calm and relaxed. This is a problem, as existing treatment before completion is likely to strengthen rather than weaken the phobia.

However one application is with people who have a fear of water (they are forced to swim out of their depth). It is also sometimes used with agoraphobia. In general flooding produces results as effective (sometimes even more so) as systematic desensitisation. The success of the method confirms the hypothesis that phobias are so persistent because the object is avoided in real life and is therefore not extinguished by the discovery that it is harmless.

For example, Wolpe (1960) forced an adolescent girl with a fear of cars into the back of a car and drove her around continuously for four hours: her fear reached hysterical heights but then receded and, by the end of the journey, had completely disappeared.

References

Wolpe, J. (1969). Basic principles and practices of behavior therapy of neuroses. American Journal of Psychiatry, 125(9), 1242-1247.

Narrative therapy

Narrative therapy is a form of psychotherapy that seeks to help people identify their values and the skills and knowledge they have to live these values, so they can effectively confront whatever problems they face. The therapist seeks to help the person co-author a new narrative about themselves by investigating the history of those qualities. Narrative therapy claims to be a social justice approach to therapeutic conversations, seeking to challenge dominant discourses that it claims shape people's lives in destructive ways. The approach was developed during the 1970s and 1980s, largely by Australian social worker Michael White and David Epston of New Zealand.

Michael White