When you think about the word ‘therapy’, what comes to mind? A few years ago the term was commonly associated with couches and tears, brooding silences and the painstaking excavation of childhood fantasies and buried memories. This was due to the influence of the school of psychoanalysis founded by Sigmund Freud in the nineteenth century, one which came to dominate popular conceptions of therapy for most of the twentieth century.
However, in recent decades a revolution has taken place. A very different model of treatment has emerged that has not only challenged many of these preconceptions, but has now successfully established itself as the most widely practised form of talking cure in the world. This model – which is actually a synthesis of several different theoretical traditions – is known as Cognitive Behavioural Therapy or CBT for short.
When the first edition of this book was published, CBT’s star was already in the ascendant. Its meteoric rise has continued and, if anything, even been accelerating ever since. Three years on, CBT looks as if it has not only changed the face of mental healthcare for ever, but its principles are routinely being applied in schools, businesses and a variety of other non-clinical settings. CBT is definitely no longer the new kid on the block. It’s everywhere and, if you have picked up this book, you will almost certainly have heard of it. When ‘therapy’ is mentioned these days, people are just as likely to call to mind aspects of CBT as they are to reach for the stereotypes and clichés of Freudian psychoanalysis.
In the UK, the profile of CBT has been raised significantly by government initiatives aimed at ensuring that more and more of us can have access to CBT on the National Health Service. At the end of the six-year rollout of the IAPT (Improving Access to Psychological Therapies) programme an additional 6000 new CBT therapists will have been trained. The goal is to make sure that by 2015 every adult that requires it should have access to psychological therapies to treat anxiety disorder or depression. However, the second phase of IAPT is also seeking to make CBT more available to children and young people, those suffering from long-term physical conditions, unexplained medical symptoms and even people with severe mental illnesses. CBT is increasingly regarded as the ‘treatment of choice’ for an ever-expanding menu of mental health problems by the National Institute of Clinical Excellence (NICE). Pioneering studies have recently been exploring the role of CBT in alleviating symptoms of epilepsy, heart disease, back pain, breast cancer and even menopausal hot flushes. It seems that scarcely a week passes without news of CBT’s successful application to yet another new problem or client group.
Innovative new ways of delivering CBT are also being developed all the time. In January 2012 an article in The Lancet reported on a small-scale study providing CBT interventions through videoconferencing and mobile phones. Even more intriguingly, a team from the University of Auckland has recently created a computer-based fantasy, role-playing game called SPARX designed to help young people learn skills to combat the symptoms of depression. If you fancy, you can take a look at the SPARX trailer for yourself on YouTube. Several websites now offer computerised CBT packages online and there are some excellent smartphone applications available to help you put CBT techniques into practice. If you are interested, you can find an overview of some of these in Appendix 1 at the end of this book.
This book aims to introduce you to both the theory and practice of CBT so you can start applying this powerful tool in your own life. The following pages will help you to:
· appreciate some of the distinctive features of the cognitive behavioural approach
· familiarise yourself with CBT’s basic principles, methods and models
· learn how to structure your own problems within the framework that CBT offers
· spot unhelpful patterns of thought and behaviour that may be contributing to your difficulties
· create practical, step-by-step strategies for tackling your problems using established cognitive behavioural techniques.
As you progress there will be exercises to help you develop your understanding of CBT techniques and the main points will be illustrated using real-life examples. I have also included some trouble-shooting tips to help you achieve the results you want.
The origins of CBT: giving Freud the slip
‘Turning on the intercom…’: this is how Aaron Temkin Beck described the breakthrough responsible for the evolution of CBT. In the 1960s Beck was an established (if rather frustrated) psychiatrist attempting to treat his patients using Freudian psychoanalysis. While Freud’s methods emphasised the importance of unpacking repressed conflicts from the past, Beck became convinced that for many of his patients the crux of their problems lay more in what they were telling themselves in the present.
He took up this line of inquiry when one of his patients admitted a number of anxious thoughts about how the consultation with Beck was going. The patient noticed several thoughts of the following kind running through his head:
· ‘I am a bad patient.’
· ‘Dr Beck will be disappointed in me.’
· ‘I am just wasting his time… He will probably want to stop seeing me…’
Beck became convinced that, whatever their original source, it was this anxiety-laden commentary that was driving his patient’s unpleasant emotions in the here and now. For Beck ‘turning on the intercom’ meant giving patients and therapists access to their internal monologue – the stream of characteristic fleeting thoughts that raced through their heads whenever they felt depressed, anxious or unsure of themselves.
It occurred to Beck that if his patients’ emotional problems were being caused by their characteristic thinking style, then training them to adopt alternative ‘healthier’ habits of thought might provide the key to relieving their symptoms.
Beck developed these promising insights and started putting them to the test in his clinical practice. In 1979 he published Cognitive Therapy of Depression, a landmark text that not only described the hallmarks of a depressive thinking style but offered a new approach for correcting them. Since that time CBT has never looked back.
Think of a time in your life when you felt particularly unhappy, fearful or stressed. Can you recall the sorts of thoughts that went through your head when you were in that state? How did you see yourself? Other people? The future?
Next time you are in a situation in which upsetting emotions wash over you, try to become aware of changes in your thinking by tuning into your thoughts and impressions. Do they have a distinctive character or quality at odds with the way you see things when feeling calmer or more upbeat?
Beck’s basic principles have been adapted and customised to create treatment packages for a huge range of conditions. Originally most closely associated with the treatment of depression and anxiety, CBT protocols now exist to help cancer patients stop smoking, to assist unemployed people get back into the workforce and to support those who suffer with more intractable mental health issues like personality disorders and psychosis. Aspects of traditional CBT are also being combined with elements of other therapeutic approaches and traditions to create an innovative raft of new therapies including Acceptance and Commitment Therapy (ACT), Mindfulness-based CBT and Cognitive Analytic Therapy (CAT). The table below gives you a very brief introduction to how CBT is continuing to evolve and play a part in shaping a new generation of ‘hybrid’ therapies.
A brilliant (but brief) guide to some common therapies and their relationship to CBT
|
Name of therapy |
Description |
Relation to CBT |
|
Psychoanalytic/Psychodynamic therapy |
Psychoanalysis aims to develop self-awareness and bring unconscious conflicts to the surface. Often associated with the influence of childhood experience and Freud’s theories of sexuality. |
CBT usually focuses more on how problems manifest and are maintained in the present rather than concentrating on early childhood experiences. |
|
Mindfulness-based therapy |
Rooted in eastern meditation traditions that emphasise the importance of being present in the moment. Mindfulness trains people to de-centre themselves and observe their emotions and thoughts in a non-judgemental way. By accepting that they are temporary, negative thoughts and feelings are allowed to pass freely in and out of consciousness. |
At first glance, Mindfulness appears to be at odds with CBT, which generally focuses on modifying upsetting thoughts rather than teaching people to tolerate them. However, Segal, Williams and Teasdale have pioneered a version of CBT that integrates elements of the mindfulness approach and has proved very effective in preventing relapse in depression. |
|
Acceptance and Commitment Therapy (ACT) |
Like Mindfulness, ACT encourages people to neutralise distressing thoughts and feelings by just ‘noticing’ them and creating a sense of an observing self that stands back from one’s experience. |
ACT places more emphasis than CBT on discovering and bringing one’s actions into alignment with personal values. |
|
Dialectical Behaviour Therapy (DBT) |
Developed as a treatment for borderline personality disorder, DBT focuses on helping sufferers evaluate the usefulness of their thoughts, manage distressing emotions and develop more appropriate social skills to get their needs met. |
Many of the techniques used in DBT are based on a combination of cognitive behavioural techniques and mindfulness principles. DBT emphasises the role of the therapist in both validating the client’s feelings and simultaneously challenging behaviours and attitudes that can cause problems for them. |
|
Person-centred counselling |
Derived from the work of humanistic psychologist Carl Rogers who believed that provided with unconditional regard and a facilitating, supportive relationship, most people will spontaneously gravitate towards healthier and more functional states of mind. |
Person-centred counselling is explicitly non-directive. The therapist encourages a client to explore issues and asks pertinent open questions but does not lead the client or attempt to teach specific skills to modulate thoughts, emotions or behaviours as in CBT. |
|
Compassion Focused Therapy (CFT) |
A form of CBT developed by Paul Gilbert that encourages people to accept their feelings and develop compassion-based cognitions that activate the self-soothing systems of the brain. |
Like CBT, CFT emphasises the content of negative thoughts but tends to target those that give rise to feelings of shame and self-criticism. Unlike most forms of CBT, CFT aims to induce specific emotional and mental states using imagery and self-affirmations, rather than rationalising unwanted thoughts using logic and trying to generate ‘balanced’ alternatives. |
|
Brief solution-focused therapy |
A set of techniques created by Steve de Shazer and Insoo Kim Berg, solution-focused therapy aims to help people find clues to solving problems by analysing existing situations in which their problems have less influence on them, or imagining scenarios in which the problem has already been resolved. The idea is that if people can behave ‘as if’ the problem has gone then they will adopt patterns of thought and action that will help alleviate it. |
Like CBT, solution-focused interventions stress the contribution of an individual’s difficulties as thoughts, feelings and behaviours in perpetuating their difficulties. Even more than CBT, solution-focused therapy is interested exclusively in how the problem manifests itself in the present. Its past antecedents are considered largely irrelevant. |
|
Cognitive Analytic Therapy (CAT) |
CAT is a treatment that usually helps people understand and compensate for the way their early relationships have shaped their behaviour in the present. Symptoms are usually as side effects of unhelpful coping styles. |
As the name suggests CAT is a hybrid of cognitive approaches and psychoanalytic theory. To the first it owes an emphasis on tackling dysfunctional thought patterns and assumptions; to the latter an emphasis on psychological defence mechanisms and the way we internalise mental models of early relationships with key carers. Like CBT, CAT is usually time-limited. One of its hallmarks is the summary letters exchanged between therapist and client. |
|
Neuro-Linguistic Programming (NLP) |
NLP is not really a cohesive therapy but a ragbag of different techniques without a particularly clear theoretical basis. It claims to unlock individual potential by teaching individuals to model the behaviours and thought processes of successful and high-functioning people. |
Like CBT, NLP is interested in changing unhelpful thought patterns and breaking destructive cycles. As in CBT, proponents of NLP claim that the mind can be taught to learn new, more helpful patterns. However, where CBT and NLP part company is that NLP has proved very difficult to assess in clinical trials, so its evidence base is virtually non-existent. Although many claim that its teachings have genuinely helped them, NLP has been accused of being pseudo-science and is certainly not endorsed by NICE. |
Why is CBT so popular?
Recently, CBT has attracted considerable attention. Its current popularity lies not only in its relevance to such a broad variety of emotional issues, but also in its ‘goodness of fit’ with the priorities and values of our times.
It is accessible
Sometimes dubbed the ‘psychology of common sense’ CBT is much more readily understood than the complex and sometimes counterintuitive theories of Freud and Jung. By mapping out the way in which our thoughts, feelings and actions all affect each other, with a little practice it becomes relatively straightforward to identify targets and strategies for dealing with whatever issues you may be facing.
It is skills-based
CBT is rooted in an educational approach. Therapy is not about being ‘fixed’ by an expert but rather learning the skills you need to solve your own problems and look after your own mental health. One criticism levelled at conventional therapy is that it can make clients emotionally dependent upon their therapist. In CBT such dependence is actively discouraged: the therapist is someone who comes alongside to facilitate and equip, and many people find this way of working less threatening. However, you always need to find the approach that is right for you.
It has a proven track record
CBT is all about evidence, so it is no surprise that from the outset Beck and his followers were fairly rigorous about measuring its effectiveness. CBT is probably better researched than most other forms of therapy and always seeks to define patients’ gains in concrete, observable terms. This can be quite hard to do within the psychoanalytic tradition. In this form of treatment progress is so wrapped up in individual experience that it can prove hard to measure in scientific terms. In making its current recommendations for which psychological treatments are most appropriate for various common mental health conditions, NICE has based its 2011 guidelines on a comprehensive review of the available research literature, much of which has been summarised by Anthony Roth and Peter Fonagy in the latest edition of their book What Works for Whom?
Conditions for which NICE recommends CBT as a treatment of choice
The fact that CBT can defend its claims using research evidence has made it all the more appealing to the modern NHS. However, it is worth remembering that even the most painstaking research has its limitations. At the end of the day even highly impressive research trial results are no guarantee that a treatment will work for a particular individual.
It can deliver rapid results
One of the major selling points of CBT is that the basic principles can be mastered relatively quickly. This means that whereas traditional psychotherapy can involve several years of weekly sessions, most courses of CBT are time-limited, aiming to equip people with the skills they need in just a few months. In May 2012 there was a heartening report of how only 15 sessions of CBT had reduced the trauma symptoms of child victims of war-torn central Africa by more than 50%. Since the results of such brief interventions compare favourably with other more time-intensive therapies, one can understand why for healthcare services juggling limited budgets the CBT model of treatment fits the bill – quite literally. For example, the NICE guidelines cite possible net savings of £1000 per person for every person treated for schizophrenia using CBT. The fact that research often suggests a relatively brief CBT intervention can also be a clinically effective one leaves healthcare providers quite naturally feeling they are looking at a win–win situation. This is why the British government is ploughing millions into developing CBT-based services.
Will it work for me?
One of the great strengths of CBT is that its principles and techniques potentially have such widespread applications. At its heart is a model of the mind that focuses on how we make sense of our experience and how that process can backfire and cause problems for us.
In fact, although CBT is associated with the treatment of diagnosable conditions, it is increasingly being used to improve performance in situations that have little to do with mental health. After all, most of us will have something to gain from a system which helps us to develop habits of rationality and healthy mindedness, and strengthens the ability to handle the emotional challenges life throws at us.
Below is a checklist of questions to help you make an informed choice about whether CBT will work for you. Simply circle the number that most applies to you.
Question 1: How self-disciplined are you?
You are embarking on a mission to change mental habits that have been reinforced over a very long period, quite possibly a lifetime. That’s going to require some self-discipline: anyone who has attempted to break a habit of any kind, from smoking to weight gain, already knows how hard this can be.
To benefit from CBT you will have to keep conscientious records of your thoughts, feelings and behaviour, often at the very times you feel least inclined to do so because you feel angry, stressed or fed up. However, make no mistake: CBT is not a quick fix or magic wand. It will only work if you persevere. Busy schedules and frantic lifestyles can make it hard to get the most out of the techniques so be prepared to make some room in your life to do your homework if you want to get the most out of CBT.
Question 2: How open-minded are you?
The essence of CBT is learning to challenge preconceptions about ourselves, other people and the world at large. You must be ready to put even taken-for-granted or cherished convictions in the dock and examine them in the light of the hard evidence.
This can be exciting but also unsettling. We are often strongly invested in our assumptions about things – even if those assumptions aren’t helping us. The beliefs that are the most rigid are often the ones that hold us back, and if you are the kind of person who has to win every argument, sees things in black and white, or always has to have the last word, then CBT may be quite challenging for you. Having said that, you may also have the most to gain.
Question 3: Are you prepared to take a long, hard look at yourself?
Although traditional psychotherapy often gets lumbered with associations of introspection and ‘navel-gazing’, cognitive behavioural methods require no less self-scrutiny. You will be examining your thought patterns and behaviour in fine detail and observing yourself intently in different settings.
You also have to be prepared for the fact that you may not like everything you discover about yourself. None of us really relish criticism, however constructive and helpful, and during the CBT process you may well be encouraged to open yourself up to candid feedback from other people.
Question 4: Are you prepared to step out of your comfort zone?
CBT does not just require you to take a ‘warts and all’ look at yourself and your behaviour. Often, its methods may require you to engage in experiments designed literally to push you to your limits. Challenging entrenched assumptions is best achieved by testing them out.
Say you hold a conviction that everyone will stare at you if you get anxious and start sweating: would you be prepared to deliberately soak your shirt with water and head out for the local shopping centre to see what happens? This is precisely the sort of task that you may end up setting yourself.
As this example implies, the situations that make us the most anxious are precisely the ones we try to avoid. CBT will ask you to do things that will feel counterintuitive, scary and just plain wrong in the interests of helping you break cycles of fear and misery that keep you trapped. It’s message to you may well be that you need to confront the very things you have been avoiding and see that the results are not as bad as you supposed. You need to ask yourself: are you really prepared for that? CBT is not for the faint-hearted.
Question 5: How much do you like solving problems?
Some people love puzzles. Other people can’t be bothered with them. If you are intending to use the techniques in this book without the help of a trained therapist who would do some of the work for you, then you will need to work in a systematic, analytical fashion as you gradually work out what is going on and spot patterns in your life that need to be changed. Setting goals, trying things out, and finding a better way is at the heart of the CBT approach.
One advantage of CBT is that it does encourage you to isolate specific areas of difficulty and work on localised problems rather than dealing with the whole picture all at once. Breaking things down into manageable chunks and generating solutions to specific issues is very much the way that CBT aims to shift the bigger emotional mountains that can otherwise leave us feeling intimidated and overwhelmed.
‘What’s the problem? What isn’t a problem? Since Paulo was born it feels like our whole world has been ripped apart.’ This was the opening response of Anita, a young woman who came into therapy with a diagnosis of severe postnatal depression.
Anita went on to list a catalogue of difficulties she and her husband were facing: since the birth he had lost his job and was struggling to cope with Anita’s low mood; there were issues as to whether Anita’s elderly mother would come and live with them; they were disagreeing about how Paulo should be brought up... . Her therapist stopped her. ‘I can see things feel really difficult for you at the moment,’ he said, ‘but if you could change just one thing right now what would it be?’ ‘I just want to feel some connection with my baby,’ Anita replied sadly.
It was agreed that under the circumstances this was a long-term goal that might take some time to achieve, but together Anita and her psychologist brainstormed some practical steps that might bring Anita a little closer to this objective. Spending time trying to interact with Paulo was just making her feel self-conscious and even more of a failure, so a plan was made that every day Anita would strap her son into a sling that held him close to her body and they would go for a half-hour walk in the countryside together.
After a while, Anita discovered that as she and Paulo took their afternoon walk the combination of physical contact and a pocket of relatively stress-free time in each other’s company began to kindle a stronger attachment between them. Anita spontaneously began chatting to Paulo as they walked, pointing out trees and birds to him. She was surprised by how instinctive this became. As her confidence in her relationship with her son increased, Anita felt less fazed by the other difficulties she was facing, and became more mentally and emotionally available to start tackling them in therapy.
Question 6: How good are you at tuning in to your feelings?
CBT requires us to become conscious of the thoughts and feelings that affect us negatively but these thought patterns are not always readily available. Some people manage difficult emotions and thoughts by blocking them out of awareness.
To work well CBT requires us to be able to separate out the different strands of our feelings because each element can point to quite different thoughts. For example, if I am conscious I am ‘fed up’ that may not help me tap into the same types of thoughts that enable me to recognise that my ‘fed up-ness’ is actually a combination of sadness (20%), anger (40%), frustration (25%) and loneliness (15%).
If you do find it hard to tune into your emotions then CBT can be an uphill struggle, although as you practise recording your moods and emotions you may be surprised by how much better you get. It is a bit like learning to familiarise yourself with a new language or appreciate a different type of music.
Expand your emotional vocabulary
As you get better at describing your feelings you will automatically become more attuned to them. Try developing a more expansive vocabulary for your emotions that allows you to make more precise distinctions between your moods. Rather than just relying on everyday labels like ‘happy’ and ‘sad’ make the effort to pinpoint your feelings more precisely by learning some more of the 3000 plus words the English language provides to describe emotions.
Question 7: How easy did you find it to rate yourself on these items?
No, not a trick question. I have already mentioned that CBT loves to measure things, and you will regularly be asked to gauge the intensity and frequency of your thoughts and feelings. You won’t have to be deadly accurate and again this is a skill you can learn as you go along. However, if you are one of those people (and I rank myself in their number) who finds personality quizzes difficult because ‘sometimes I am like this and sometimes a bit like that’ then CBT may prove quite testing for you at times. To paraphrase the nuns in The Sound of Music, when it comes to quantifying your thoughts and feelings, CBT can feel very much like trying ‘to catch a cloud and pin it down’. But with practice you’ll soon get the hang of it. However, it really can be helpful to develop this skill because at the point you recognise, for example, that your anxiety level has dropped from a 7 to a 3, you know you are getting somewhere!
How did you do?
If you found yourself scoring between 0 and 2 on more than four items I would suggest you either consider another form of therapy or at least try CBT with the support of a trained practitioner who can help you in the areas that may come less easily to you.
However, also recognise that where you score now on these scales is not necessarily indicative of where you will end up after practising some of the techniques described in this book. Low scores certainly do not rule CBT out of the equation. It simply means that there may be some aspects of the approach that may demand more from you. If you do find yourself struggling to apply the techniques you read about in the rest of this book, don’t forget you can always consult the trouble-shooting guide on page 273.
It is always helpful to be aware of potential pitfalls and hazards from the outset and to make informed choices. Then you can prepare yourself and develop strategies to compensate – a very CBT way to approach matters.
I admit it: I always skip these kinds of tasks in books too. However, if you were seeing a psychologist for treatment you would probably be doing something similar to this exercise in the initial session. The reason is that people who reflect actively upon their motivations and their own learning process do tend to engage better, learn more deeply and stick with it when difficulties present themselves.
So, before you proceed any further, sit down somewhere quiet and attempt to answer the following questions:
· What am I hoping to gain from learning more about CBT?
· What difficulties am I likely to face as I attempt to put the advice in this book into practice? (For example, consider when you will make time to practise techniques or whether there are aspects of your personality that might make it difficult for you to get to grips with the approach.)
· Is there anything I can do to help myself overcome any potential difficulties?
· What difference will CBT make to my life?
Now read on…
By now you are hopefully starting to have a sense of what CBT is all about. The level of commotion surrounding this relatively new therapy is extraordinary, but behind the hype there are sound, tried and tested psychological principles and insights that deliver results. It is not a quick fix, but the nature of CBT is such that most people should be able to enjoy significant benefits from the approach, even without the help of a professional therapist. If you think you might be one of those people, brilliant reader, then read on…