What is Cognitive Behavioral Therapy?

Cognitive Behavioral Therapy (CBT) views the client as an active participant in his or her own treatment. It is seen as beneficial if the client understands exactly what is involved in treatment, and the theory behind why certain treatment protocols are chosen.. Here is what you could expect if you sought CBT treatment for an anxiety problem.

“The focus of Therapy is to help the client learn new ways to think about and behave towards situations which create anxiety.”

CBT is formulated on the hypothesis that significant contributions to the development and maintenance of anxiety disorders include faulty learning experiences and distorted thinking. The focus of therapy is to help the client learn new ways to think about and behave towards situations which create anxiety, so that they are ultimately free to behave in ways that they desire without the threat of undo stress and fear.

Therapy includes first getting a thorough history of the client’s life experiences and psychological functioning, and then assessing whether a medical or psychiatric consult is necessary. A medical consult is often helpful to rule out possible physical/medical causes for anxiety symptoms, and a psychiatric consult, though arranged only occasionally, is especially important for persons who are so impaired by their anxiety symptoms that they may not be able to utilize therapy effectively unless assisted by medication.

Early stages of therapy involve educating the client about the nature and experience of his or her particular disorder, often providing or suggesting readings. Next, the client learns how to better observe, record, and report his or her own symptoms. This helps to get a clearer understanding of the client’s idiosyncratic expression of the disorder- that is, not everybody with, say, Panic Disorder, has the same symptoms under the same conditions. The better we understand the specific way an anxiety disorder is experienced by a client, the better able we are to design interventions for that client.

“Together, Clients and Therapists decide  which relaxation technique to focus on.”

The next stages of therapy involve educating the client about cognitive behavioral interventions and applying them to their anxiety symptoms. In general, we begin with “grounding techniques,” which are designed to help a client “get a grip” when feelings of loss of control and panic are overwhelming. These are followed by relaxation training, such as learning “paced” or “diaphragmatic” breathing. Other relaxation techniques, such as Progressive Muscle Relaxation or Autogenic Relaxation, are sometimes applied. Together, client and therapist decide which relaxation techniques to focus on. The client practices and records progress in between therapy sessions, and reports to the therapist on progress and/or problems, and adjustments and changes are made as necessary.

Next, we shift focus to “Cognitive Restructuring,” which is a very specific method wherein the client learns how to identity the thought processes which are fueling the anxiety experience. In essence, one asks, “What am I saying to myself about this situation that is making me feel so anxious?” Once these thoughts are identified, the client, through a very specific set of questions, critically analyzes the validity of these thoughts, and develops a replacement set of thoughts based on a more rational appraisal of the situation. Unlike “positive thinking,” which essentially focuses on having a person tell him or herself, “It’ll be OK,” or something similar, cognitive restructuring is based on examining one’s own thoughts and critically analyzing them. As with all skills developed in CBT, this restructuring process is practiced and recorded by the client, and reviewed with the therapist in session.

“Ultimately, a person with an anxiety disorder must learn to face his or her fears.”

The next stage in therapy involves some kind of “exposure” work. Ultimately, a person with an anxiety disorder must learn to face his or her fears. However, with the support of the therapist, and armed with a full understanding of the disorder, grounding, relaxation, and cognitive restructuring techniques, the client is better prepared to face these fears. Also, by developing a hierarchy, or “stepladder” of fears, the client challenges him or herself only a little at a time, beginning with the least challenging fears, and building up strength and self- confidence, moving upwards, to more feared situations. Finally, long-term maintenance of gains, relapse prevention, and “lapse response protocols,” or the ways in which to deal with symptoms which may re-emerge, are reviewed.

“The focus of treatment is on the reduction and even elimination of anxiety symptoms.”

As you can see by the procedure described above, the focus of treatment is on the reduction and even elimination of anxiety symptoms. However, in addition, throughout therapy, additional issues are often addressed. If the initial assessment reveals specific trauma or issues related to family history, these dynamics may be incorporated into the CBT. Comorbid conditions may exist as problems separate but often related to the anxiety condition, most commonly depression and/or substance abuse. These and other comorbid conditions are also addressed in treatment as needed.

Issues around self- esteem and interpersonal functioning almost always are addressed as part of treatment. The development of, and/or improvement in, the support systems outside of therapy is promoted. Finally, the respect, support, and encouragement in the therapy relationship itself is crucial to the success of treatment.

OCD—Some special considerations

Typically, with Obsessive Compulsive Disorder (OCD), the treatment components of Grounding, Relaxation, and Cognitive Restructuring are less emphasized, in favor of the more direct behavioral approach of “Exposure with Response Prevention.”  This exposure treatment varies in it’s specifics, depending on the particular presentation of OCD symptoms.  Ultimately, though, it involves identifying what it is that the OCD obsessions are demanding of the client, and coaching the client to NOT give in to them through a variety of techniques.

About CBT