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Cognitive Behavior Therapy (CBT) is a theoretical orientation based on a social learning model that highlights how an individual’s thinking impacts how he/she feels and how he/she behaves (Leahy, 1999). The concept that our perceptions determine how we experience reality has been documented as far back as “Plato’s Cave” when Socrates described how a group of men chained in a cave saw shadows dancing across the wall in front of them. The shadows are real to them until one day one of the men turns around and sees the shadows are cast by figures walking behind them. After that day, the shadows are no longer a reality. Leahy (1999) states cognitive therapy can be seen as an attempt to get the client to “unchain himself and see beyond the cave” (p.30). CBT is defined as a therapeutic approach used to explore connections to modify the way a person perceives situations and their reaction to those situations (Beck, 1995). CBT has clearly defined goals that involve reframing a person’s thoughts, beliefs, and perception in order to facilitate emotional and behavioral change (Leahy, 1999). This involves the interaction between thoughts, feeling and behaviors. CBT approaches therapy from the framework that the client is responsible for making the needed changes because he/she has contributed to his/her own psychological problems due to their thought’s effect on his/her emotional response and behavior (Beck, 1995; Ellis, 2004). According to Vivyan, (2009) “CBT says it’s not the event that causes our emotions, but how we interpret that event – what we think or what meaning we give that event or situation” (p. 39). Because thoughts influence a person’s emotional, behavioral, and physiological reaction, facilitating a person’s ability to evaluate his/her thinking, emotions, physiology and behavior could have a positive therapeutic effect (Beck, 2005). Additionally, it teaches clients to recognize and correct negative thoughts and beliefs that may be the cause of many of their problems (Beck, 2005). For example, exaggerated or biased ways of thinking can be maintained by stress and cause a person to experience depression, anger, or anxiety.
Principles and Elements of Cognitive Behavior Therapy
The highlight of Cognitive Behavior Therapy (CBT) is the principle, based on the social learning theory, that our thinking impacts how we feel and behave. The focus of CBT is to identify negative or false beliefs and test or restructure them (Ellis, 1998). Further, CBT can be applied in many ways, to include concentrating on restructuring, modifying behavior, and/or developing alternative coping skills. The “B” part in CBT is behavior and involves a therapeutic approach that is goal-oriented and treats emotional and behavioral disorders as maladaptive learned responses that can be replaced by healthier responses through training (Williams & Garland, 2002). Additionally, CBT is present centered and focuses on what is happening in the current moment rather than exploring the past. It also makes it easier for clients to recognize and understand thoughts that may be leading to irrational worries and fears by being thought focused (Leahy, 1999).
Additionally, using a cognitive restructuring approach can help the client and therapist explore cognitive distortions and this in turn can lead to a change in behavior through behavior modification (Williams & Garland, 2002). In order to break the cycle, therapists help clients notice how their thoughts and feelings affect their behavior, which can change what they think and what they do. Therapists who focus on CBT also help the client “deconstruct” his/her experience and recognize that the perception is what gives the experience meaning (Leahy, 1999).
The behavioral component of CBT also includes respondent, cognitive and operant conditioning in addition to addressing exposure and desensitization. Respondent conditioning is used to help clients construct their exposure to anxiety producing situations and thus reduce their sensitivity to the anxiety producing events (Stangier, Schramm, Heidenreich, et al., 2014). Operant conditioning uses reinforcement and punishment to create associations between behaviors and the consequence of those behaviors. This involves pairing a neutral cue with an aversive stimulus that causes a fear response to be elicited when the subsequent stimulus is presented to the now conditioned cue (Marin, Camprodon, Dougherty, & Milad, 2014). Operant conditioning also explains why people do what they do and studying how both positive and negative reinforcers affect behavior can have practical use to treat some problems. For example, when working with a person who desires to change his/her behavior, the therapist can find out what purpose the undesired behavior serves. Once that’s identified a clinician can help him/her come up with behavior strategies to modify that behavior and replace it with something healthier.
The most famous example of classical conditioning is John Watson’s research with Little Albert. Watson conditioned him to fear by pairing a neutral stimulus (a white rabbit) with an unconditioned stimulus (a startling noise). This demonstrated that people can develop an emotional response to a neutral stimulus (Masters, Burish, Hollon, & Rimm, 1987). This is seen in individuals that experience traumatic events who can be triggered by a neutral cue that has become aversive. For instance, someone who is held up at gunpoint while taking money out of an ATM will come to associate ATMs with this life-threatening event. ATMs can continue to elicit strong emotional responses weeks after the traumatic event. Pavlov also modified behavior using classical conditioning. He did this by conditioning dogs to salivate at the sound of a tone. Understanding that neutral stimuli can become aversive helps us understand why some people develop anxiety disorders after experiencing anxiety-provoking events. These theories of respondent, classical, and operant conditioning are used in CBT to help clients identify distressing thoughts and employ behavioral therapy techniques to modify their thoughts and behaviors (Marin, 2014). Further, CBT gives therapy structure and helps clients focus on challenging their belief patterns and correct their thinking errors. This is done by focusing on the presenting problem in the current moment (Burns, 1999; Ellis, 1988). By helping the client interpret their experience in a different way the therapist and client work together to develop constructive ways of thinking that will produce healthier behaviors and beliefs. Additionally, CBT enables therapists to stay focused by taking interest in more than the client’s symptoms and life history. They also give attention to the client’s interpretation of his or her life events. Lastly, CBT allows therapists to set an agenda and structure the sessions by having clearly defined goals and this can be critical when time is limited (Leahy, 1999).
Techniques and Definitions of CBT
In order to help clients understand how their response to situations affects their behavior, CBT utilizes practice and homework. The intent is to help clients learn new skills that assist them in understanding the link between thoughts, feelings, and behaviors. This may involve issuing homework that allows them to test their beliefs against reality, such as replacing negative thoughts with more realistic thoughts or by using thought records by recording negative thoughts in a journal. By assigning and demonstrating homework the therapist takes on the role of a teacher or coach who encourages clients to practice techniques learned during therapy (Creed et al., 2014). The following is a list of techniques and definitions used in this paper:
- Negative Cognitions/Thinking Errors: Thoughts and beliefs held by a client that can serve to limit their functioning.
- Relaxation response: A condition in which muscle tension, cortical activity, heart rate, and blood pressure decrease and breathing slows.
- Negative thought pattern: Any type of thinking that leads to negative consequences.
- Values Card Sort: Values define what an individual wants out of life and how he/she is going to behave to get it. They determine how an individual will use his/her time, energy and resources.
- Maladaptive Beliefs: False and unsubstantiated thinking that causes and maintains emotional problems.
- Diaphragmatic breathing: Breathing through progressive relaxation intended to relax the muscles and reduce anxiety.
Efficacy of CBT
Throughout this research, CBT was shown to be the most effective form of treatment for numerable forms of mental illnesses to include; depression, anxiety, panic disorders, chronic pain, eating disorders and addictions (Creed, Wolk, Feinberg, Evans, & Beck, 2014). The targets of CBT are precisely chosen to be measurable and studies have shown that individuals who undergo CBT benefit in many ways. One of those is by improved brain activity suggesting that CBT also improves brain functioning (Creed et al., 2014). According to Porto, Oliveira, Volchan, & Ventura (2009) CBT leads to neurobiological changes in anxiety disorders (as detected by neuroimaging techniques). CBT “modified the neural circuits involved in the regulation of negative emotions and fear extinction in judged treatment responders” (Porto et. al, 2009, p 114). Neuroimaging studies also revealed that dysfunctions of the nervous system were changed due to CBT, although there were methodological limitations, (Porto et al., 2009).
Functional analysis of behavior is considered to be the heart of CBT. According to Scharwachter (2008) the link between clinical practice and experimentally verified learning principles is what helps explain the consequences of behavior. Hanley, Iwata, and McCord (2003) further define functional analysis as an examination of the causes and consequences of problem behavior. In addition, they explain functional analysis as being influenced by the individual’s environment where the consequences of behavior can reinforce or punish behavior that will make it less or more likely for the behavior to be repeated in the future. Using functional analysis helps therapists generate hypotheses to explain the motives that keep problem behaviors going which can assist clients in selecting techniques to best address the behavior During treatment, using functional analysis helps identify events where the client has difficulty coping or circumstances that may trigger the client.
Some of the mental disorders that can benefit from the functional analysis of CBT include: anxiety, depression, dissociative identity disorder, eating disorders, generalized anxiety disorder, hypochondriasis, insomnia, obsessive-compulsive disorder, and panic disorder without agoraphobia (Hanley, Iwata, & McCord, 2003). A successful tool used in functional analysis includes homework that allows clients to identify the antecedents, behavior, and consequences of that behavior (Hanley, Iwata & McCord, 2003). An example of this is the therapist conducting a functional analysis of a recent episode of avoidance, cognitive distortions, or self-defeating behavior with the client in order to identify the cause of the behavior. The environmental functions of both wanted and unwanted behavior needs to be explored in order to achieve a conceptual position of the client’s behavior. One way to investigate this is by having the client think about the memory and explore what was going on during the time they were trying to avoid the situation or cognitive distortion, such as how they were feeling, what was going on before and after the event, and the positive and negative consequences. This includes exploring what they saw, where they were, what they were smelling, hearing, and tasting.
Casey is a 31-year-old Caucasian woman who reported depression and anxiety that she stated stemmed from negative feelings about herself, low self-esteem and a history of self-harm and substance abuse. She depicted feeling hopeless, crying uncontrollably, losing interest in activities she used to enjoy, significant weight loss, fatigue, low self-esteem, and an inability to sleep. She described a “negative thought pattern” consisting of negative cognitions about her abilities and aptitudes which disclosed she experienced a reality that was different from her ideal self. She identified not feeling she was “worthy” of being loved because she had done “unforgivable things.” She also reported not knowing who she was and “losing” herself in relationships by becoming whoever she thought her partner wanted her to be. During the second appointment after the intake interview, which included her psychological history, trauma, and family history, I introduced the rationale for CBT treatment, and went over the structure for the following sessions. I asked the client what her goals were and she appeared to have good insight into her presenting problems and stated she wanted to “do something other than talk.” She appeared to be motivated to change and eager to find out why she was so critical of herself. During our initial session, Casey expressed she did well with homework because she needed to have defined and achievable goals. This helped guide our sessions using a CBT approach.
After the initial appointment, I introduced CBT and talked about starting skills training. We went over the CBT skills workbook together and Casey chose what she wanted to focus on based on what she identified as causing her the most hardship. We agreed that in subsequent sessions we would go over the homework together and she would pick the assignment for the following week. We also agreed that as time went on I would sometimes make suggestions on what her following assignment should be based on her concerns in the session.
I also set the agenda for future sessions into three parts, although this agenda remained flexible and was intended to set a structure for our meetings, which is something Casey stated she found comforting. During the first part, which was scheduled to last from 10 – 15 minutes I would check in with Casey, listen to her concerns, and ask if there was anything she wanted to make sure we covered. During the second part, which was scheduled to last approximately 20 – 30 minutes, the agenda was introduced and the topic was correlated to address Casey’s current concerns. During the remainder of the time possible high risk situations were discussed, Casey’s understanding of the topic was explored, and homework for the following week was assigned. During follow up session she was eager to go over her homework and talk about what it had brought up for her and how she was utilizing her newfound skills.
Some of the symptoms she revealed she was experiencing were considered, such as social withdrawal and a sense of worthlessness which included depression and feeling useless. She identified isolating herself and drinking to get drunk in order to keep people from getting close to her. She stated she did this out of fear that others would discover she was a “fraud.” She also reported believing other people “tolerated” being around her but she did not believe people actually wanted to be around her. When asked to list what she did well she shrugged her shoulders, looked at the floor, and could not name anything she felt she did well. When asked to list what she did not do well she became energized and immediately began to list things she was not good at until I stopped her to point out how difficult it was for her to identify things she did well but how quick she was able to identify the things she was not doing well.
When inquiring where the cognitive distortions and automatic negative thoughts came from, such as “I should be perfect” and “I am worthless” we uncovered that those were messages she received from her mother and had internalized. Her assumption was that people would discover she was a “fraud” if they got to know her and her automatic thought was that she would be rejected and others would find her to be boring. She also blamed herself when her relationships failed stating it was because she was not able to “be herself.” This self-doubt was caused by the shame she carried due to her previous drug use.
She was then asked to keep track of her negative thoughts as they came up during the day by using a Dysfunctional Thought Record. The tool we used to do this was pulled out of a functional analysis worksheet found on the CBT workbook. The first column was the situation that provoked an emotional response; the second column was the feeling that came up during the situation; the third column listed her automatic thoughts; and the fourth column was the alternate response possible that could help her identify different ways she could think of the situation to help her restructure her thoughts. The goal was to explore the origin of those cognitive distortions that were reinforcing the belief that she was worthlessness and unlovable because it was contributing to her maladaptive responses in relationships
She also identified a history of previous suicide attempts, drug use, running away from home, staying in abusive relationships, continually moving to “get away from” herself and quitting jobs. She stated she quit her jobs because she felt she never did a good enough job and this was “proof” of her inadequacy.
Additionally, I handed her a list of negative cognitions and positive cognitions and I challenged her cognitive distortions by interrupting her thought pattern and asking her to replace it with a more positive one, such as, “I have value.” When she declared an automatic negative thought, I would point it out and ask her to reword it and replace it with a positive cognition. For instance, when she said “should” statements, such as, “I should have done better on the test” I would ask her to rephrase it and she would look at the list of negative and positive cognitions and rephrase it with a positive cognition, such as “I did the best I could.” We continued to do this with other cognitive distortions that were contributing to her low self-esteem. Additionally, she took a picture of the list of negative and positive cognitions and stated she would pull it up whenever she caught herself being self-critical. She indicated she would replace maladaptive assumptions with practical assumptions, such as changing the following statement, “I’m a failure if I don’t get a perfect score on a test” to something more realistic, like “Everyone makes mistakes and I don’t have to be perfect.” We discussed the consequences of negative thinking and how it could continue to be an obstacle to self-change and lead to unhappiness.
Casey prided herself on being fit and stated she found yoga to be helpful in feeling calm and grounded. When she identified feeling overwhelmed by her demanding school work as a nursing student and her job as a medical assistant, I decided to teach her relaxation techniques and mental distractions in order to help her reduce stress and improve her mood. We also practiced diaphragmatic breathing to interrupt her racing thoughts by having her repeat, “I am calm, I am peaceful” when she exhaled. I also used visualization by having her look out the window and identify the vastness of the sky. We practiced sitting with our feet firmly planted on the ground, feeling the good energy come out of the earth and through the body lifting the negative thought and throwing it at the sky. The exercise was a visualization technique where she would toss her worry at the sky and let it go.
In order to help Casey identify who she is and what she stands for, I turned to values-based work by using the card sort. This is an interactive experience used to help her figure out what she finds important and how she is living her life according to her values. As a result, we were able to define goals more clearly and work together on ways she could stay true to herself and live according to her values. I also put the values she chose on the table and whenever she talked about something she was doing that aligned with her values I would point to the card in order to highlight the value she was living up. If she mentioned doing something that did I knew did not align with her values I would ask her how that aligned with her values and we would discuss what motivated the behavior and she would explore how she could modify it. My goal was to help her recognize her negative thinking and how it might be causing her anxiety and depression. She identified the need to be perfect and this could have been keeping her trapped in her own unrealistic standards.
Limitations and Strengths
One of the goals of CBT is to lessen dependence on the therapist by building a collaborative relationship and fostering autonomy in the client (Beck, 1995). This approach may appeal to clients who have limited time and/or money to go to therapy. Since the directive skills of CBT can be learned on an average of 16 weeks and can later be conducted on their own, this may have lifelong effects in a shorter time than other therapeutic methods (Beck, 1995). This is also helpful during practicum and internship when time is limited to one or two semesters. Furthermore, having structured sessions reduces the possibility that sessions become “venting sessions” and the limited time may allow for more therapeutic work to be accomplished. On the other hand, clients may feel the focus on positive thinking minimizes the importance of their personal history and the impact on external factors (Ellis, 1998). Other clients may feel CBT intellectualizes their emotions which may feel superficial to them (Burns, 1999). Additionally, CBT many not be appropriate for clients with traumatic brain injury or a brain disease that impedes their ability to participate in their treatment. Lastly, CBT many not appeal to clients who are not willing to take an active role in their treatment process or clients who do not want to be burdened by homework.
Barriers and Facilitators
Cultural values and beliefs can be a barrier to therapists when working with an unfamiliar culture. I was working with an Alaskan Native client who corrected my approach by helping me understand that asking him to focus on himself came across as selfish and a better way to help him would be to reframe therapy in a more collectivistic approach that helped him think he was giving back to his family and community. This taught me that I need to ask myself if I knew who I was talking to and if I had prepared myself to talk to them in a way that was beneficial and culturally sensitive so our time together would be constructive for them.
For the most part I found CBT to be effective based on client’s self-report of being able to question the validity of their automatic negative thoughts and replace them with more accurate and balanced alternatives. Additionally, CBT encourages clients to challenge distorted thoughts and change destructive patterns of behavior by focusing on solutions. Another benefit of CBT is that it is simple to convey and most clients find it easy to understand and implement. However, one of the most telling factors that CBT will be beneficial for a client is his/her willingness and ability to be open to reframing their cognitive distortions. Lastly, having a supervisor who was knowledgeable about CBT and took the time to listen and instruct me on the tools available for CBT has been invaluable in helping me understand and implement therapy in a way that feels genuine.
I’m drawn towards this therapeutic approach because it aligns with my personal values of self-reliance and autonomy. Cognitive Behavior Therapy is an approach to therapy that has more studies than any other theoretical orientation because it focuses on the present situations clients want to change and targets the thoughts and behaviors that are maintaining the problem behavior. It also helps clients look for ways to immediately improve their wellbeing. Additionally, CBT offers treatment goals that are easy to measure and implement. My military background has given me a solution focused attitude and an appreciation that aligns with CBT because it is measurable and encourages clients to take action towards their recovery. Most importantly, it empowers clients by giving them a sense of control over their lives and offers them coping skills and solutions they can implement on their own outside of therapy.
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