Cognitive Behavioral Therapy (CBT) in a Nutshell

Cognitive Behavioral Therapy, or CBT, is one of the most common forms of psychotherapy available to day. If you are getting therapy, there’s a good chance you’re getting CBT. But what is CBT? What makes it different from other forms of treatment?

The Theory of CBT

Cognitive behavioral therapy is, unsurprisingly, a combination of cognitive theory and behavioral theory.

Image result for captain obvious
Just doing my job.

Behavioral theory looks at what determines what actions we take. The two major theoretical cornerstones of behavioral therapy are classical conditioning, i.e. Pavlov’s dog, which says that we associate behavioral responses to stimuli, and operant conditioning, i.e. Skinner boxes, which says that we are more likely to do behaviors that are reinforced, and less likely to do behaviors that are punished.

Cognitive theory looks at how our minds represents and processes information. When we take in new information from our senses, our mind identifies it and catalogues it based on our previous experiences, then make decisions about how to act based on that information. Your hands tell you that you are gripping something hard, round, and covered in leather, your feet tell you that there are pedals under then, your ears hear a squealing sound and your eyes see bright red lights filtered through glass. Your mind puts this all together and says “that sonafabitch is cutting you off, hit the brakes, fool!”

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Ignore the fact that the car in the picture is clearly parked.

Thoughts and behaviors, along with feelings, broadly make up the entirety of what the conscious mind does – and they all act together.

3 circles in a cycle. 1st circle - cognitions (thoughts), 2nd circle - emotions (feelings), 3rd circle - behaviours
Source

In the example above, I think “That asshole is cutting me off.” (thought) that makes me angry (feeling). Because I am angry I flip him the bird (behavior). Once I get closer I see that “he” is actually an 80 year old frail woman doing her best, so now I feel guilty (feeling) and start thinking about how I’m the real asshole (thought) and so on and so on throughout the day.

How does this apply to mental illness?

Mental illness doesn’t come from these momentary, immediate reactions like the one I described above so much as it does from patterns, styles or habits in thought or behavior. Now, any time you represent reality in your mind, you’re focus on certain details and neglect others, which leads to predictable errors in thinking. This happens to all of us. And any time you engage in a behavior, that behavior either gets reinforced, because it had the intended effect, or punished, because it didn’t. After enough practice, certain types of behaviors or certain ways of thinking start to come a little easier to us, which of course means that certain emotions are more likely.

Let’s take depression. For whatever reason, Person A is more prone to pessimistic thinking. They tend to expect the worst, have low self-esteem, feel like things are out of their control, etc. So their go-to assumption is that things are going to suck. That person tends to wake up in the morning and think “man, work is going to suck”, which makes them feel sad. They decide to call in to work, which temporarily makes them feel better. So that category of behavior, which we can call decreasing activity, gets reinforced. They start to think about what it says about them as a person that they called into work, which just makes them feel worse, which just makes them want to do less.

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We’re in no position to judge here.

Same thing for fear. For whatever reason, Person B is more prone to catastrophic thinking. They expect that bad things are going to happen to them, and in contrast to person A who doesn’t care about themselves enough to really worry about it, person B really wants the bad thing not to happen. Say they are worried about being in a plane crash. Every time they go on a plane, it’s a very painful (frightening) experience because they think it might crash. In contrast, when they take a train, they feel a sense of relief. That relief reinforces that pattern of thinking and that fear response, so it actually makes them more afraid of the flying.

How does this apply to therapy?

In both scenarios I described above, these thought and behavior patterns are happening automatically. Person A isn’t saying “I expect only bad things to happen to me today, so I will stay in bed in order to increase my sadness,” just like Person B isn’t saying “I believe that this plane will likely crash, so I will take a train to my destination, reinforcing my fear of flying”. Person A just feels crappy so they stay in bed and watch Netflix, and Person B just hates flying, so they choose to take trains.

Image result for planes trains and automobiles
Or other forms of transit

In CBT, you use particular frameworks, like the 3 Cs or thought records, to start identifying these automatic patterns of thinking. Once you’ve identified them, you connect them with these predictable errors in thinking I mentioned before. You reassess your thinking based on this new perspective, then take steps to hammer in this new idea. Person B learns the real facts about air travel safety. Person A starts to practice thinking that maybe things won’t be so bad, maybe by remembering good events, or practicing self-affirmations.

Image result for stuart smalley
Ignore the fact that this guy was run out of Washington for sexual harassment.

That’s the cognitive portion. Behaviorally, this works by identifying the problematic behavior that is being reinforced – avoidance, isolation, aggression, drug use – finding an alternative that works better, and practicing that alternative. This might also work on changing the environment so that those problematic behaviors aren’t reinforced. Person A would start increasing their activity level, through behavioral activation. Person B would do exposure therapy.

What does this actually look like?

Cognitive behavioral therapy has been accused of being a gimmicky therapy, which is fair because there is a strong focus on techniques. Because the problem lies in habits of thinking or behaving, the treatment focuses on structured frameworks to apply the new thoughts or behaviors, which helps keep people from slipping into old habits.

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“I feel like there was something I was supposed to be doing…”

The CBT sessions tend to be pretty structured themselves. The therapist will check in on your understanding of the last session. You and your therapist will set an agenda of points to cover. You’ll cover those points, focusing on pulling out the thoughts and behaviors that underlie the concerns. There might be a brief lesson in the session – either new information or learning a new skill. And, there’s almost always homework. The homework will involve practicing the new pattern – because your old patterns are firmly established, you have to apply extra work to applying the new one.

There are different subtypes of CBT for certain conditions. Prolonged Exposure, Trauma-Focused CBT and Cognitive Processing Therapy are specific treatments for PTSD. Interoceptive exposure is a specific treatment for panic disorder. Exposure and response prevention is for OCD. These all have the same theory and framework as basic CBT, they just have different ways of addressing the problematic thinking and different skills to practice to focus on the given issue.

Pros and Cons of CBT

Like I said, CBT could be accused of feeling a bit gimmicky. You might feel like you’ve gone back to school, homework and all. CBT focuses less on the therapeutic relationship than some other treatments, like psychodynamic therapy or interpersonal therapy, but a good CBT therapist will still be empathic, accepting, and warm.

Cognitive Behavioral Therapy has the strongest evidence support for treatment of specific conditions, but that’s not as much of a benefit as you might think. CBT explicitly focuses on reducing symptoms as the primary goal of treatment, so of course it’s going to show more improvement than a treatment like interpersonal therapy, which has a harder to measure focus on increasing an individual’s sense of connection – with others and with themselves.

Plus, the research on CBT is showing that its effectiveness is actually going down. This might be because therapists are getting lax in their CBT delivery – not setting firm agendas, going easy on the homework, etc. Also, some of the concepts that were novel in the 1970s when CBT was developed – like the whole idea of “self-esteem”, or exercise helping your mental health – are more common knowledge now, so there’s not as much value added by a course of CBT therapy. Even with this decline, CBT is still one of the most effective treatments for most conditions available today.

Nerd Mind’s Take

I do more CBT than I do any other treatment. Mostly, that’s because it’s still got some of the best evidence basis, and I think that I am the kind of CBT clinician that can still develop a good therapeutic relationship. I also like that CBT is so modular, so I can draw in techniques or ideas from other treatments, like existential therapy, or Mindfulness, without it feeling like a big departure from how we’ve been doing things.

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I have literally had people do this during CBT treatment.

However, there are some issues that I don’t think CBT is the right approach for – like if the central issue is something we can’t do anything about, like loss of a loved one or incurable illness. Here are the situations that I like CBT best for:

  • Person is ready to make lifestyle changes.
  • There’s a clear central issue (or several issues).
  • It’s the person’s first time in therapy

Notice that I’m not saying particular diagnoses or client populations, because again CBT is so adaptable that way. It’s still the gold standard of treatment for many conditions, and there’s good reason for that – it works!

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