CBT is a talking therapy that looks at the links between our thoughts or perceptions, actions, and feelings, and is focused on the here and now rather than the past. It is an active, directed, time-limited and structured therapeutic approach, based on the assumption that the way a person interprets the world determines their emotions, behaviours, and physiology. To put it simply, what CBT looks at can be represented by the 5 Areas Model:
CBT equips therapists with a broad range of techniques that they can use to engage with clients in therapy and address their current problems, but also to enable them to practice solutions between the therapy sessions. CBT was originally developed to treat depression however it is now used to treat a number of mental health conditions, such as anxiety, phobias, PTSD, OCD, bipolar disorder or psychosis, among many others.
The most influential model of depression is that of Aaron Beck, which proposes that the client’s perception of the event, rather than the event itself, leads to the activation of negative self-schemas and automatic negative thoughts which consequently affects their thoughts, moods, and behaviour.
A number of interventions have been developed over the years that address the above issues. The purpose of the interventions is to explore dysfunctional assumptions, challenge negative thoughts, or enhance behavioural activation by encouraging clients to engage in activities they used to enjoy. The client is encouraged to engage in such tasks between sessions. As a matter of fact, these homework tasks are a crucial part of therapy. Through engagement in homework tasks clients learn to apply new skills and strategies in their everyday lives, thus developing their sense of self-efficacy and are able to become ‘their own therapists’ in the future.
The collaborative nature of the therapeutic relationship is the key principle in CBT. Through the course of therapy the therapist is explicit about their work and clients are active participants. The collaborative nature of therapy is evident in the therapist’s negotiating interventions with the client, inviting them to provide feedback, communicating with the client about their disorder – thus facilitating their understanding of the problem.
Before the therapist decides on which intervention techniques to employ, they conduct an assessment. The aims of the assessment are:
The Five Areas model is a popular assessment tool which can provide a clear and structured summary of the client’s presenting problems. The model has been praised for being jargon-free, accessible, and engaging, making it a useful tool to identify the client’s short, medium, and long-term targets, providing focus for treatment, and establishing the sequence of problem areas to be tackled.
During the assessment the therapist might also use measurement tools which will give them an opportunity to evaluate the effectiveness of the interventions used. Such tools can take the form of scaling questions which, on a scale from 0 to 10, assess the severity or frequency of symptoms; or the therapist may use a standardized questionnaire or inventory. The most common measures in the assessment of depression are the Hospital Anxiety and Depression Scale and the Beck Depression Inventory.
Following in-depth assessment the therapist will form a case formulation, also known as conceptualisation, which aims to bring together the knowledge of the client’s problem with the knowledge of the cognitive model of the presenting problem, and the relevant empirical research, evidence, and practice, in order to devise the most appropriate intervention plan. It is an important part of the process and should be constructed with utmost care. When shared with the client it can instil hope that the symptoms they could not understand or thought had no solution can actually be explained, managed or changed. It also provides normalization to the client’s problems and can identify client’s strengths and resilience.
An agenda takes the form of a list of items which will be discussed in a session and is established at the beginning of each session. It may include revisiting points from the previous sessions, reviewing homework, adding new topics which might be proposed by either the therapist or the client, and helps to prioritise items. It is a collaborative process and adds a structure to the session, helping to ensure that limited time is well spent on relevant topics
The number of interventions is so vast it wouldn’t be possible to cover everything in one article so here are just a few examples.
Psychoeducation – learning about your problem is the first step to overcoming it. It is important to understand not only how the therapy works but also how your mind and body work together. Understanding your symptoms can provide comfort of knowing that they can be managed and that they are more common than you might have thought. A CBT therapist may either discuss certain things with you (such as the 5 Areas Model), give you some handouts to read later or can direct you to online resources.
Relaxation techniques – learning techniques such as Progressive Muscle Relaxation, Relaxed Breathing, or mindfulness that can alleviate physical symptoms.
Daily Activity Diary – diaries can be very helpful to gather a little bit more information about your activities and how they make you feel. They are especially useful in treatment of depression. The therapist will ask you to keep track of your activities in 1 or 2 hour time-slots and to rate the intensity of your mood and your sense of enjoyment and achievement. You can then look at the diary together to identify the activities you enjoyed most and schedule more of those.
Graded exposure – this is simply facing fears and this can be used to tackle anxieties or phobias. The first step would be to decide on the hierarchy, i.e. finding out what situation is the least scary and what is the most scary and building a fear ladder between the two. Exposure involved you going into these feared situations repeatedly until they naturally become less scary. The exposure has to be prolonged so you have a chance to get used to the situation. It has to be hard enough to cause you some discomfort but it also has to feel doable to you.
Behavioural experiments – these can be very helpful when treating panic or phobia. You may be engaging in safety behaviours, i.e. avoiding doing certain things, but the therapist may encourage you to drop these behaviours and test your prediction. For example, in case of phobia you may be asked to specify the worst that could happen, evaluate evidence for and against predicted catastrophe, identify your safety behaviours and drop them, and then review what happened.
CBT will have equipped with you with important skills that need to be practised continually so you stay in good shape. It is normal to have a lapse especially if you’re experiencing a particularly stressful time in your life. However, it is important to know how to avoid a relapse and having a Relapse Prevention Plan in place can help you to achieve that. The plan will help you to identify when you are becoming most vulnerable, recognise the warning signs, and know how to act on them.
Remember that lapses are normal and going through CBT is really hard work so be kind to yourself and don’t forget to reward yourself! 🙂
A lot of what I mentioned in the article is readily available online – please go to CBT Resources page for links.