COGNITIVE-BEHAVIORAL THERAPY
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COGNITIVE-BEHAVIORAL THERAPY
 
AN OVERVIEW:

   Cognitive-Behavioral Therapy (CBT) has been proven both clinically and by numerous research studies to be an effective form of treatment for many psychological conditions. These include anxiety disorders such as panic disorder, shyness and social anxiety, phobias, OCD, generalized anxiety, PTSD, depression, low self-esteem, substance abuse, and relationship problems. CBT is what I refer to as "emotional education" in that the therapist serves as a teacher, tutor and coach to provide a great deal of information about emotional functioning. CBT combines two effective forms of treatment: Cognitive therapy and Behavior therapy.
 
Cognitive therapy: Cognitive therapy focuses on identifying, challenging and modifying the individuals negative, anxiety-provoking cognitions (thoughts). These thoughts are also referred to as anxiogenic cognitions - meaning anxiety generating thoughts. These thinking patterns cause the symptoms of anxiety, depression and low self-esteem, and contribute to behavioral problems such as overeating and substance abuse. It is difficult for an individual to identify their own irrational and negative thought patterns, and more difficult to change them even if identified. It requires the assistance of a knowledgeable therapist to help identify and modify these thinking patterns. When one is feeling negatively, it is often because they are thinking negatively. These negative thoughts are often out of line with reality in that they are more negative than realistic. These negative thinking patterns are also referred to as irrational as opposed to rational, because they are unrealistic, and unrealistically negative. Therefore, as I often stress to patients, thinking more rationally is not positive thinking, it is simply more realistic thinking which happens to be more positive than their usual irrational and negative thoughts. The problem with the notion of positive thinking is that it often strikes people as pie-in-the sky, overly optimistic, hopeful, and temporary thinking. Rational thinking is more positive, is reality based and not just optimistic, and can therefore become permanent thinking.
      Cognitive therapy with Panic Disorder focuses on identifying the core fears about the physical, or somatic, sensations being experienced which create anticipatory anxiety that escalates to panic and contributes to agoraphobic avoidance. Critical to cognitive therapy with panic is the identification of the Catastrophic Misinterpretations that are responsible for the escalation of anxiogenic thoughts into full-symptom panic. In contrast, cognitive therapy with Social Phobia involves identification and modification of the core fears of negative evaluation by others, as well as the beliefs and avoidant behaviors that prevent disconfirmation of those assumptions. The identification, challenging and modifying of these beliefs are part of cognitive-restructuring.
 
Behavioral therapy: Here the treatment focuses on modifying behavior to aid in modifying underlying cognitions, beliefs and thinking patterns. This process helps to lessen the connection between situations and  reactions to those situations, and reduces the intensity of those automatic reactions. This is an active and collaborative therapy. By this meaning the therapist is actively involved in the therapy vs. passive and merely providing support while the patient works to figure out their problems. It is also a collaboration between the therapist and patient as they devise behavioral strategies and work together in their implementation. The behavioral treatment or testing of assumptions, involves desensitization and exposure techniques. Desensitization procedures involve the use of fantasy to imagine and rehearse the successful management of a frightening situation while in a relaxed state. This is in vitro desensitization, which helps to facilitate more successful management of the stressful situation in real life, or in vivo exposure. So desensitization techniques use imagery to imagine and master situations in the minds eye. Exposure techniques incorporate experiencing the feared situations, either in a controlled manner in the therapy session called interoceptive exposure, or in real life: in vivo exposure.
 
Benefits of CBT: One of the most prominent benefits of CBT is the strong maintenance of treatment progress. In other words, the benefits of CBT are long-lasting, unlike medication that is of benefit only as long as it is used. CBT helps people "unlearn" their fears and avoidant behaviors, and new learning occurs: the learning of relative safety in relation to the original feared situation. There is also strong evidence that exposure techniques in CBT are more effective when the therapist also helps the individual recognize their SAFETY BEHAVIORS. These are behaviors the individual with anxiety engages consciously and unconsciously to help them avoid their imagined catastrophic fate when confronted with their feared situation.
 
CBT vs Medication: Many studies have demonstrated the superiority of CBT over medication alone in the treatment of anxiety disorders. Some studies have shown an additive value in the use of medication along with CBT but other studies have demonstrated no additional benefit to addition of medication to effective CBT.  It appears that there is benefit in adding exposure techniques to the treatment of an individual already on medication, and less value in adding medication to the treatment of an individual engaged in CBT. The benefits of such combined therapy seem to disappear when medications are discontinued. Two large scale studies provided strong evidence that once medication was withdrawn, individuals on combined therapy did worse than those receiving CBT only. It is the longer term maintenance of treatment gains that truly makes CBT alone a more effective form of treatment. It appears that CBT alone is superior to combined CBT and medication due to the impact on learned safety behaviors. Research shows that "safety learning" (or learning to challenge and disprove the catastrophic hypothesis) as opposed to safety behaviors, occurs with exposure techniques. The use of medication undermines the effectiveness of safety learning, as the individual attributes much of their success to medication, another safety behavior. When the medication is removed, the return of fear is likely. Despite these disadvantages, some individuals need medication to bring their anxiety down to manageable levels to facilitate CBT. When it comes time to discontinue medication, additional therapy, both CBT and supportive, are important to complete the internalization of safety learning. And some leading experts such as Dr. David Burns recognize such downside to combined drug and talking therapies that he advocates tapering off a sedative medication such as Xanax or Klonopin before beginning CBT. He also believes there is no benefit to SSRI antidepressant medication and cites many studies that have demonstrated antidepressant medications to be no more effective than placebo. There is growing evidence and general knowledge of this, including the unethical lengths the pharmaceutical industry has gone to skew research studies and even suppress studies that demonstrate these facts.
 
 
GENERAL COGNITIVE MODEL: 
 
"SITUATION"
leads to:
"AUTOMATIC THOUGHTS & IMAGES"
leads to:
"REACTION":
either:
EMOTIONAL
BEHAVIORAL
PHYSIOLOGICAL
 
      In other words, a situation such as a thumping heart; causes automatic thoughts and images such as the thought of a heart attack and images of having a heart attack; causes a reaction both emotional (fear, terror, panic), behavioral (looking for help); and physiological (further palpitations, light-headedness, feeling faint, sweating, flushing).
      CBT focuses on helping the individual identify their situations, thoughts and images, or what I refer to as the "thought-feeling" chain. By identifying ones chain of thoughts and feelings that culminate in a panic attack, an individual is empowered to intervene in that chain and abort a developing panic attack.  When these anxiogenic (anxiety producing) thoughts are identified, CBT helps the individual challenge their rationality/feasibility, and modify/eliminate them. I use an Anxious Thought Record to help the individual complete this exercise both in the therapy session as well as on their own.
 
 
ANXIOUS THOUGHT RECORD
  • WHAT IS THE FEARED SITUATION?
  • WHAT IS THE NEGATIVE/ANXIOUS THOUGHT?
  • WHAT IS THE FEARED CATASTROPHE? (SPECIFIC!)
  • WHAT PERCENT DO YOU BELIEVE IT TO BE TRUE? (0-100%)
  • WHAT FACTS SUPPORT FEARED CATASTROPHE?
  • WHAT FACTS SUPPORT NON-CATASTROPHIC EXPLANATION?
  • WHAT PERCENT DO YOU NOW BELIEVE THE CATASTROPHIC FEAR TO BE TRUE? (0-100%)

      This exercise is difficult initially without therapeutic assistance, because many of the thoughts and images are difficult to isolate and identify on one's own. With therapeutic assistance one comes to recognize their pattern and develop the capacity to more successfully engage this process on their own.  

 

COGNITIVE DISTORTIONS:

      The following are common irrational, negative and self-defeating thoughts and patterns of thinking that contribute to negative feelings: anxiety, depression, anger and guilt. These thoughts and thinking patterns also contribute to relationship and behavior problems. The identification, challenge and modification of these negative, self-defeating beliefs constitute a significant part of CBT.

  • All or Nothing Thinking - You look at things in absolute, black and white categories.
  • Overgeneralization - You view a single negative event as a never ending pattern of defeat.
  • Mental Filter - You dwell on the negatives and ignore the positives.
  • Discounting Positives - You insist your positive qualities don't count.
  • Jumping to Conclusions - You jump to conclusions not warranted by the facts.
    • Mind Reading - You assume that people are reacting negatively to you.
    • Fortune Telling - You predict that things will turn out badly.
  • Magnification or Minimization - You blow things way out of proportion or shrink them.
  • Emotional Reasoning - You reason from your feelings instead from logic. For example: "I feel  like an idiot so I must be an idiot.
  • Should Statements -  You think in terns of "should, shouldn't, must, ought and have to".
  • Labeling - Instead of saying "I made a mistake", you tell yourself "I'm a loser, jerk, idiot" etc.
  • Self Blame and Other Blame -
    • Self Blame: You blame yourself for something you weren't entirely responsible for.
    • Other Blame: You blame others and overlook ways you contributed to the problem, thereby reducing your sense of power.

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