Cognitive Behavioural Therapy
Cognitive Behavioural Therapy (CBT) is one of the most popular styles of psychological therapy in Australia today. So what is it, and why all the hype?
What is CBT?
Cognitive Therapy - now more commonly known as Cognitive Behavioural Therapy - was developed from the early 1960s by Dr. Aaron T. Beck. It was developed to modify unhelpful thinking and behaviour, within a structured, short-term, present-oriented psychotherapeutic framework. This therapy is based on the premise that unhelpful ways of thinking influence the way a person feels and what they do, and that this is common across psychological difficulties. The power of thoughts in determining an experience is demonstrated simply using the A-B-C (Antecedent - Behaviour - Consequence) model. For example, say your partner does not arrive home when you expect them to, and when you try to call, it goes straight to voicemail. You experience an immediate thought, They’ve been in a car accident on the way home. These are the antecedents - that which occurs prior to the behaviour. You respond by attempting to contact your partner’s work colleagues, and then move on to contacting hospitals - these are the behaviours. As a consequence, you neglect to make the dinner you had planned, you experience overwhelming anxiety, and when your partner arrives home, they are annoyed that you responded in the way you did, as now their work colleagues need to be notified that everything is okay. If, however, your original thought was, They must be caught up with work, you probably would have responded by letting your partner know that you’d appreciate better communication if they know they’re going to be home late. With this response, you make the planned dinner, and do not experience any emotions other than slight irritation toward your partner for not communicating with you more effectively. These are very different outcomes for the same situation, which was determined by the original thought.
Therapy is based on a formulation of client’s difficulties, which identifies aspects of the client’s current experience, such as the unhelpful thoughts contributing to their difficulties, the problematic behaviours being engaged in, their physical experience of the problem, and their emotional experience. Triggers to this experience and underlying vulnerabilities are also identified. For example, a person with performance anxiety may have a shy temperament and history of being bullied (underlying vulnerabilities), where their difficulties of anxiety (emotion) are precipitated by team meetings, where they are often called upon to speak (trigger). Prior to meetings, this person may have thoughts such as I’m going to embarrass myself, nothing I say is worth listening to. Their experience of anxiety is felt in the body as sweating, shaking, and a racing heart (physical sensations), and in response, they often call in sick on days that meetings occur, or will spend the meeting avoiding eye contact with others (behaviours).
Therapy will often start by working together to identify the client’s experience - to identify their thoughts, emotions, physical sensations, and how they are behaving in response to situations. Unhelpful ways of thinking are identified, and thoughts are challenged, with more balanced thoughts identified. This generally begins with negative automatic thoughts, and then client’s underlying beliefs about themselves, others, and the world are addressed. Clients then begin to understand how thinking differently can impact their overall experience. Different ways of behaving are experimented with, so that the client can start to challenge their beliefs about the outcomes of their behaviour.
The strategies used to challenge thoughts and behaviours are delivered in a structured way within sessions. It requires active participation with the client in session, as well as practice between sessions. Over time, these new ways of thinking and behaving become more automatic for clients. Because therapy focuses on a specific problem, it requires the client to be able to collaborate with the therapist in identifying a specific problem to develop treatment goals for. As a structured therapy, it is time-limited, with straightforward anxiety and depressive disorders successfully treated in 6-14 sessions. Focus is on symptom reduction, teaching the client to be their own cognitive-behavioural therapist with the skills to challenge unhelpful thoughts and beliefs.
There are many types of therapies that fall under the umbrella of cognitive-behavioural therapies, which are united by the commonalities of emphasising the importance of empirical support for the effectiveness of the therapy, and by the emphasis on targeting cognitions to influence behavioural change. Although many therapies fall under this umbrella, each therapy is unique in its content, delivery, and focus. Some therapies that fall under the umbrella of cognitive-behavioural therapies include Mindfulness-Based Cognitive Therapy, Metacognitive Therapy, Schema Therapy, Acceptance and Commitment Therapy, Dialectical Behavioural Therapy, amongst many others. When I refer to CBT in this post, I am specifically referring to that which is described above, and not all therapies that fall under its umbrella.
What can CBT help with?
CBT has been adapted to treat a range of difficulties. Because CBT is structured, strategy-based, and time-limited, it is easy to evaluate in research settings, and so a lot of research exists to support its effectiveness. It has shown to be effective as its adaptations (shown in brackets) in the treatment of (but not limited to):
Generalised anxiety disorder
Obsessive compulsive disorder (exposure and response prevention)
Panic disorder
Post-traumatic stress disorder (trauma-focused)
Social anxiety disorder
Phobias (exposure)
Eating disorders (with eating disorder focus)
Depression
Psychotic disorders
Sleep disorders
Substance use disorders (including Motivational Interviewing)
When is CBT not appropriate, or when are other therapies more appropriate?
The strategies taught in CBT are useful skills that many people would benefit from learning, but this style of therapy is not for everyone, and that’s okay! Most of the above-listed disorders that CBT is helpful for are also effectively treated with other styles of therapy. Some clients simply don’t like therapy that is structured, skills-based, and/or time-limited, nor do they want to practice skills in between sessions. Although CBT can be delivered in a less structured way, there are also other styles of therapy that may be more appropriate for those clients.
It is not always helpful to focus on a client’s thoughts in terms of the thought content, but rather to focus on the way that they think; here, Metacognitive Therapy or Acceptance and Commitment Therapy may be more appropriate. Indeed, many anxiety disorders - although treatable with CBT - may be better treated with these types of therapies.
There are a number of disorders where CBT has not been found to be the most evidence-based treatment. For example, Borderline Personality Disorder is more effectively treated with Dialectical Behaviour Therapy, Schema Therapy, or Psychodynamic Therapy. Also, pain disorders are more effectively treated with Acceptance and Commitment Therapy. Further, in presentations where thinking is not central to the program - such as for those who have experienced complex trauma - therapies other than CBT are more appropriate.
My use of CBT in therapy
During our first sessions together, I will work with clients collaboratively to develop a treatment plan. The treatment plan will be based on the client’s presenting problem, their preferences for the style of therapy they’d like to receive, and their commitment to therapy. If CBT is an evidence-based treatment for the client’s specific difficulties, where a client’s thoughts a central to their problems, and the client is motivated to engage with a therapy that is structured, time-limited, strategy-based, and which aims to achieve symptom reduction, we will consider this as a treatment option. Sometimes, CBT is also a starting point in therapy to achieve symptom reduction, before moving on to a style of therapy that is longer term and delves more deeply into past experiences and underlying beliefs, such as Schema Therapy.
As well as being a Cognitive Behavioural Therapist, I also deliver a range of other therapies, including Metacognitive Therapy, Acceptance and Commitment Therapy, and Schema Therapy.
