How you prepare for Cognitive Behavioral Therapy
You might decide on your own that you want to try cognitive behavioral therapy. Or a doctor or someone else may suggest therapy to you. Here’s how to get started:
- Find a therapist – You can get a referral from a doctor, health insurance plan, friend or other trusted source. Many employers offer counseling services or referrals through employee assistance programs (EAPs). Or you can find a therapist on your own — for instance, through a local or state psychological association or by searching the Internet.
- Understand the costs – If you have health insurance, find out what coverage it offers for psychotherapy. Some health plans cover only a certain number of therapy sessions a year. Also, talk to your therapist about fees and payment options.
- Review your concerns – Before your first appointment, think about what issues you’d like to work on. While you can also sort this out with your therapist, having some sense in advance may provide a starting point.
Steps in CBT
The basic steps in a cognitive-behavioral assessment include
- Step 1: Identity critical behaviors step 2: Determine whether critical behaviors are excesses or deficits
- Step 3: Evaluate critical behaviors for frequency, duration, or intensity (obtain a baseline)
- Step 4: If excess, attempt to decrease the frequency, duration, or intensity of behaviors; if deficits, attempt to increase behaviors
CBT typically includes these steps
- Identify troubling situations or conditions in your life – These may include such issues as a medical condition, divorce, grief, anger, or symptoms of mental illness. You and your therapist may spend some time deciding what problems and goals you want to focus on.
- Become aware of your thoughts, emotions, and beliefs about these problems – Once you’ve identified the problems to work on, your therapist will encourage you to share your thoughts about them. This may include observing what you tell yourself about an experience (self-talk), your interpretation of the meaning of a situation, and your beliefs about yourself, other people and events. Your therapist may suggest that you keep a journal of your thoughts.
- Identify negative or inaccurate thinking – To help you recognize patterns of thinking and behavior that may be contributing to your problem, your therapist may ask you to pay attention to your physical, emotional and behavioral responses in different situations.
- Reshape negative or inaccurate thinking – Your therapist will likely encourage you to ask yourself whether your view of a situation is based on fact or on an inaccurate perception of what’s going on. This step can be difficult. You may have long-standing ways of thinking about your life and yourself. With practice, helpful thinking and behavior patterns will become a habit and won’t take as much effort.
Length of therapy
CBT is generally considered short-term therapy — about 10 to 20 sessions. You and your therapist can discuss how many sessions may be right for you. Factors to consider include:
- Type of disorder or situation
- The severity of your symptoms
- How long you’ve had your symptoms or have been dealing with your situation
- How quickly you make progress
- How much stress you’re experiencing
- How much support you receive from family members and other people
CBT combines cognitive therapy and behavior therapy
CBT focuses on changing unhelpful or unhealthy thoughts and behaviors. It is a combination of two therapies: ‘cognitive therapy’ and ‘behavior therapy’. The basis of both these techniques is that healthy thoughts lead to healthy feelings and behaviors.
- Cognitive therapy – The aim of cognitive therapy is to change the way the person thinks about the issue that’s causing concern. Negative thoughts cause self-destructive feelings and behaviors. For example, someone who thinks they are unworthy of love or respect may feel withdrawn in social situations and behave shyly. Cognitive therapy challenges those thoughts and provides the person with healthier strategies. Many techniques are available. One technique involves asking the person to come up with evidence to ‘prove’ that they are unlovable. This may include prompting the person to acknowledge the family and friends who love and respect them. This evidence helps the person to realize that their belief is false. This is called ‘cognitive restructuring’. The person learns to identify and challenge negative thoughts, and replace them with more realistic and positive thoughts.
- Behavior therapy – The aim of behavior therapy is to teach the person techniques or skills to alter their behavior. For example, a person who behaves shyly at a party may have negative thoughts and feelings about themselves. They may also lack social skills. Behavior therapy teaches the person more helpful behaviors. For example, they may be taught conversational skills that they practice in therapy and in social situations. Negative thoughts and feelings reduce as the person discovers they can enjoy themselves in social situations.
Treatment with CBT
The details of treatment will vary according to the person’s problem. However, CBT typically includes the following:
- Assessment – this may include filling out questionnaires to help you describe your particular problem and pinpoint distressing symptoms. You will be asked to complete forms from time to time so that you and your therapist can plot your progress and identify problems or symptoms that need extra attention
- Personal education – your therapist provides written materials (such as brochures or books) to help you learn more about your particular problem. The saying ‘knowledge is power’ is a cornerstone of CBT. A good understanding of your particular psychological problem will help you to dismiss unfounded fears, which will help to ease your anxiety and other negative feelings
- Goal setting – your therapist helps you to draw up a list of goals you wish to achieve from therapy (for example, you may want to overcome your shyness in social settings). You and your therapist work out practical strategies to help fulfill these goals
- The practice of strategies – you practice your new strategies with the therapist. For example, you may role-play difficult social situations or realistic self-talk (how you talk to yourself in your head) to replace unhealthy or negative self-talk
- Homework – you will be expected to actively participate in your own therapy – for example, the therapist may ask you to keep a diary – and you are encouraged to use the practical strategies during the course of your daily life and report the results to the therapist.
- Graded Exposure – Exposure is a cognitive behavioral therapy exercise designed to reduce anxiety and fear through repeated contact with what is feared. This has been to shown to be among the most effective treatments for any psychological problem. The underlying theory has to do with avoidance of things that we fear resulting in increased fear and anxiety. By systematically approaching what you might normally avoid, a significant and lasting reduction in anxiety takes place.
- Successive Approximation – Successive approximation is a cognitive behavioral therapy exercise that helps people tackle difficult or overwhelming goals. By systematically breaking large tasks into smaller steps, or by performing a task similar to the goal, but less difficult, people are able to gain mastery over the skills needed to achieve the larger goal.
- Mindfulness Meditation – Mindfulness meditation is a cognitive behavioral therapy exercise that helps people disengage from harmful ruminating or obsessing by learning to connect to the present moment. Mindfulness comes from Buddhist meditation and is the subject of a significant amount of new research on the effective treatment of psychological problems.
- Skills Training – Skills Training is a cognitive behavioral therapy exercise to help remedy skills deficits, and works through modeling, direct instruction, and role-plays. The most common subjects of skills training are social skills training, assertiveness training, and communication training.
- Problem Solving – Problem Solving is a cognitive behavioral therapy exercise to help people take an active role in finding solutions to problems. Chronic mood problems or repeated disappointment can result in people taking a passive role when difficult situations arise. By teaching people effective problem-solving strategies, they are able to regain control and make the best of difficult situations.
- Relaxation Breathing Training – Relaxation training is a cognitive behavioral therapy exercise designed to help people reduce physiological symptoms of anxiety, such as shortness of breath, rapid heart rate, dizziness, etc. By reducing the body’s anxious arousal, people are able to think more clearly, thus increasing feelings of comfort and further decreasing anxiety symptoms.
Origins of Cognitive Behavior Therapy
The idea for developing this form of psychotherapy took root when Aaron Beck began to notice that his patients with depression often verbalized thoughts that were lacking in validity and noted characteristic “cognitive distortions” in their thinking. His empirical observations led him to start viewing depression not so much as a mood disorder but as a cognitive disorder. Based on his clinical observations and empirical findings, Beck outlined a new cognitive theory of depression. He published Cognitive Therapy for Depression (Beck, Rush, Shaw, and Emery, 1979) after having published a study that evaluated and demonstrated the efficacy of cognitive therapy. The combination of a detailed treatment protocol manual with outcome research was an innovation in psychotherapy practice that had only previously been attempted by behavior therapists in treating discrete behavioral problems. By accomplishing the same feat with a more complex set of clinical interventions that included cognitive, emotional, and behavioral components, Beck pioneered a model for what psychologists many years later defined as an “empirically validated psychological treatment.”
Other clinicians and researchers became interested and began developing CBT treatment protocols and evaluating their efficacy. Specific treatment protocols were developed for some psychiatric disorders. As behavioral strategies were incorporated, the term cognitive therapy changed to cognitive behavior therapy. Today CBT is the most extensively researched of all psychotherapies with several evidence-based treatment protocols.
Three aspects of cognition are emphasized:
Underlying beliefs or schemas
An individual’s immediate, unpremeditated interpretations of events are referred to as automatic thoughts. Automatic thoughts shape both the individual’s emotions and their actions in response to events. For example, a friend may cross you in the hallway and not say hello to you. If you were to have an automatic thought of “he hates me,” or “I have done something to anger him,” it is likely to impact your mood and cause you to feel upset and also to behave in an avoidant manner when you see him next. On the other hand, if you had the automatic thought, “he is in a hurry,” you would not be too concerned, and you would not be avoidant when you were to see him next.
CBT is based on the observation that dysfunctional automatic thoughts that are exaggerated, distorted, mistaken, or unrealistic in other ways, play a significant role in psychopathology.
Errors in logic are quite prevalent in patients with psychological disorders. They lead individuals to erroneous conclusions. Below are some cognitive distortions that are commonly seen in individuals with psychopathology:
Dichotomous thinking – Things are seen regarding two mutually exclusive categories with no shades of gray in between
Overgeneralization – Taking isolated cases and using them to make wide generalizations
Selective abstraction – Focusing exclusively on certain, usually negative or upsetting, aspects of something while ignoring the rest
Disqualifying the positive – Positive experiences that conflict with the individual’s negative views are discounted
Mind reading – Assuming the thoughts and intentions of others
Fortune telling – Predicting how things will turn out before they happen
Minimization – Positive characteristics or experiences are treated as real but insignificant
Catastrophizing – Focusing on the worst possible outcome, however unlikely, or thinking that a situation is unbearable or impossible when it is just uncomfortable
Emotional reasoning – Making decisions and arguments based on how you feel rather than objective reality
“Should” statements – Concentrating on what you think “should” or “ought to be” rather than the actual situation you are faced with or having rigid rules which you always apply no matter the circumstances
Personalization, blame, or attribution – Assuming you are completely or directly responsible for a negative outcome. When applied to others consistently, the blame is the distortion
Underlying beliefs shape the perception and interpretation of events. Belief systems or schemas take shape as we go through life experiences. They are defined as templates or rules for information processing that underlie the most superficial layer of automatic thoughts. Beliefs are understood at two levels in CBT:
The central ideas about self and the world
The most fundamental level of belief
They are global, rigid, and overgeneralized
Examples of dysfunctional core beliefs
“I am unlovable.”
“I am inadequate.”
“The world is a hostile and dangerous place.”
Consist of assumptions, attitudes, and rules
Influenced in their development by the core beliefs
Examples of dysfunctional intermediate beliefs
“To be accepted, I should always please others.”
“I should be excellent at everything I do to be considered adequate.”
“It is best to have as little as possible to do with people.”
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