What is Cognitive Behavioral Therapy?
A FAMILY OF THERAPIES
Cognitive Behavioral Therapy refers to a family of psychotherapies all of which are based on the idea that thoughts, feelings, and behaviors are interrelated—AND—that the best way to make changes in how we feel is to change the way we think. I said it’s a family of psychotherapies because, from the start, there have been multiple and distinct forms of cognitive therapy and new forms have continued to be developed. The two primary forms of Cognitive Behavioral Therapy are Rational Emotive Behavior Therapy which was created by Albert Ellis and Cognitive Therapy which was created by Aaron T. Beck. One source of confusion is that the name ‘Cognitive Therapy’ or ‘CT’ is often mistakenly used to refer to all types of cognitive therapies. For clarity, I will use the term ‘Cognitive Behavioral Therapy’ to refer to the family of related psychotherapies and only use the abbreviation ‘CT’ when I am specifically referring to Beck’s distinct variety of cognitive therapy. In my practice I make use of both techniques but I primarily use Rational Emotive Behavior Therapy (REBT) because I find it to be more applicable to the serious difficulties that clients often bring into treatment.
WHAT IS RATIONAL EMOTIVE BEHAVIOR THERAPY?
Rational Emotive Behavior Therapy is one form of Cognitive Therapy, arguably the original form. Rational Emotive Behavior Therapy (REBT) was created by Albert Ellis, considered by many to be one of the greatest psychologists of the twentieth century, when he became dissatisfied with the effectiveness of more traditional psychodynamic treatments. REBT continues as a thriving force in psychotherapy carried on through the work of the Albert Ellis Institute and a generation of psychotherapists personally trained by Albert Ellis.
REBT’s central idea is that our self-defeating irrational beliefs are the source of our disturbance. REBT also emphasizes the way our beliefs can create either healthy or unhealthy negative emotions.
HOW LONG DOES COGNITIVE BEHAVIORAL THERAPY TAKE?
Cognitive Therapy with a trained and qualified therapist is designed to be a short-term treatment. You should be discussing the most important aspects of your difficulty in only a few sessions. Many people experience a benefit after only 8-12 sessions. However, in order to make this kind of rapid progress, you must be willing to spend your sessions learning the process of Cognitive Behavioral Therapy and to work outside the session to complete worksheets and other assignments that will help you use what you have learned.
DOES CBT WORK?
Yes! Cognitive Behavioral Therapy is a collection of the most widely used and broadly researched evidenced-based treatment for improving mental health. The type of Cognitive Behavioral Therapy we will emphasize in this book (REBT) specifically has been shown to be reliably effective across a wide variety of studies [1] and there is strong support for its central tenet, that emotional disturbance is associated with irrational beliefs [2].
HOW DOES COGNITIVE THERAPY WORK?
Cognitive Therapy works by improving the way we think about ourselves, others, and what happens to us. We can summarize the method used to do this as, “Discover, Review, Improve, and Practice” (DRIP). In order to accomplish this, we must first discover the beliefs that we use to evaluate the situations we face. Only then can we review our beliefs to ensure that they are helpful, rational, and true. Once we can see these patterns, we will be able to improve our beliefs by making sure they are logical, beneficial, and true. In order to really make the benefits of this process stick, we need to practice these beliefs and turn them into a new mental habit.
Core Skills of Rational Emotive Behavior Therapy
Distinguish between thoughts, emotions, and behaviors
Distinguish between healthy and unhealthy emotions.
Notice your thoughts
Uncover your beliefs
Learn to use the ABC Model
Improve your beliefs
Recognize the four Irrational Belief styles
Learn the four Rational Belief styles
Support your new beliefs with changed behavior
THOUGHTS, FEELINGS, AND BEHAVIORS
One skill that is very important for the use of CBT is to understand the relationships between thoughts, feelings (or emotions) and behaviors. This, at first glance, may seem very straight forward, but trust me, it is definitely worth taking a little time to clarify this now so it doesn’t trip you up later. Let’s look at each of these.
THOUGHTS
Thoughts are mental activity that usually take the form of sentences in your mind. I say they are usually sentences because they can sometimes be images in our mind. Thoughts are things you (internally) say to yourself.
EMOTIONS
Emotions (or Feelings) are body states that we feel as a result of evaluating situations. Emotions include such things as happiness, sadness, and anger. Emotions are things you feel.
A very useful concept is emotional granularity—how many distinct emotions does a person use to explain their experiences. Some people have very low emotional granularity—they get by with just a few emotional words. Many people may only distinguish between happy, sad and angry. And some people might not even distinguish between sad and angry but might use some other world like “down” or “pissed off.” Think about emotional granularity like a pack of crayons. The more you have the clearer a picture you can create. If two people are going to create an image and one has a 4-pack and the other has the 64 pack with the sharpener in the back, who is going to create a more detailed image. Having low emotional granularity is a deficit that that will make it harder for individuals to name, describe and address their emotional states. Without the right words to describe emotions, a person may more likely resort to other unhelpful behaviors such as aggression. The process of therapy naturally increases a persons emotional granularity. But it may be helpful for us to focus on it directly.
BEHAVIORS
Behaviors are activities that you do. Usually thes are things that you can be observed by others doing.
Even though these categories seem pretty straight forward there were grey areas in between. For example, people often use the word “feel” to express their thoughts. “I felt like she didn’t really like me.” Is an expression of a thought, although the action of saying this is a behavior. What about something like worrying as in “I spent the whole afternoon worrying about the test.”? Here the action of worrying seems to be a behavior—the person spend a long time performing this behavior, but it was a kind of mental behavior that someone else coundn’t really observe. The behavior or worrying, however, is problably made up of dozens (hundreds? Thousands?) of individual thoughts such as “I am going to fail the test” and “When I fail the test it will be horrible” and “I am never going to be successful.”
THE RELATIONSHIP BETWEEN THOUGHTS, FEELINGS, AND BEHAVIOR.
There is no simple relationship between thoughts, feelings, and behaviors. Each one can give rise to the others. For example, I can have the thought that I that “I am always going to be alone” and this can lead to feeling sad (an emotion) and this can lead to drinking excessive amounts of alcohol (a behavior). But it can go the other way as well, going for a walk (a behavior) might lead to an improved mood (emotion) and spark thoughts of gratitude for the good things in my life. So the bottom line is that thoughts can give rise to emotions and behaviors, behaviors can give rise to thoughts and emotions, and emotions can give rise to thoughts and behaviors. Sometimes this is referred to as the triangle of CBT (with thoughts, emotiongs and behaviors being the points of the triange and two-way arrows connecting them.
Now, with all that said, in CBT we usually do use a simplied model of this. Often in our examples we will focus on thoughts causing unwanted emotions or thoughts causing unwanted behavions. This is because, most often in therapy people are most motivated to address their negative feelings (for example, their depression and anxiety) or their unwanted behaviors (for example, yelling at their kids, substance abuse). When we set the goal to change emotions or behaviors the most effective way to do that is to change our thinking—this is one of the main ideas of CBT.
This does not mean that behavioral approaches (for example using schedules, rewards, strategies, problem-solving, exercises, social skills training, dietary changes, learning organizational techniques, and modifying incentives) are not powerful techniques. They are, and they can be critical for success in many circumstances. Nevertheless, Cognitive Behavioral Therapists tend to believe that thought-based skills are even more powerful because, once learned, they will apply to many different situations. Moreover, the right mindset would ensure that any behavioral changes you make will be more successful.
More information about CBT is available in the free Introduction to CBT Workbook.
To discuss with me whether CBT is the right treatment of for you call my office staff to set up an initial consultation. Click here to set up an appointment.
Footnotes:
[1] David, D., Cotet, C., Matu, S., Mogoase, C., & Simona, S. (2018). 50 years of rational-emotive and cognitive-behavioral therapy: A systematic review and meta-analysis. Journal of Clinical P, 74(3), 304-318. doi: 10.1002/jclp.22514. Epub 2017 Sep 12. The full text is available here: http://onlinelibrary.wiley.com/doi/10.1002/jclp.22514/full.
[2] Vîslă, A.,Flückiger, C.,Grosse Holtforth, M., & David, D. (2016). Irrational beliefs and psychological distress: A meta-Analysis. Psychotherapy and Psychosomatics, 85(1), 8-15. The full text is available here: http://albertellis.org/wp-content/uploads/2018/02/REBT-Theory-Metaanalysis.pdf
