Cognitive-Behavior Therapy

Written by John Rapp, MSW, LCSW

Cognitive-behavior therapy (CBT) represents a collection of therapies with a unifying philosophy, capable of treating problems ranging from eating disorders to insomnia.  Cognitive-behavior theory posits that while we may not have much direct control distressing emotions, we at least have some control over our thoughts and, in particular, our behavior.  Cognitive-behavior therapies attempt to address problems by examining and changing thoughts and behaviors that interfere with wellbeing.

CBT has its roots in the treatment of depression.  At the time of its creation, the predominant theories of psychoanalysis suggested that depression stemmed from the “turning inward” of anger which patients could not otherwise tolerate consciously.  Aaron Beck, widely considered to be the creator of modern CBT, did not perceive his depressed patients to be angry.  Instead, he noticed that depressed individuals have characteristic styles of thinking (like black and white thinking) and relentless, self-critical thoughts which caused them distress.  He sought to treat depression by identifying and modifying depressogenic thoughts and behaviors.

Unlike other theories which suggest that emotional problems stem from unresolved issues in early development or unconscious conflict, cognitive-behavior therapies focus on the “here-and-now” and on observable thoughts/behaviors.  The hypothetical causes of the problem are deemphasized; factors keeping the problem going in the present are the focus.  The belief is that if whatever is maintaining a particular problem can be addressed, the problem will improve and may continue to do so even after therapy has concluded.  In order to demolish a house of cards, one need not remove every card, but rather the pillars and foundational pieces.  Thus, discovering the “cause” of a particular problem is viewed as largely irrelevant in CBT for treatment occur.  What if there are multiple causes for a mental health issues, representing an array of biological, social, and psychological factors?  Even if all of the “causes” could be identified in therapy, would this alone result in change?  Or would one still have to work on changing anyway?

Self-monitoring is common in cognitive-behavior therapy.  Self-monitoring involves noticing and tracking thoughts, feelings, or behaviors which the therapy is attempting to modifying.  Tracking moods over time, keeping a food diary, and counting episodes of self-injury are all examples of self-monitoring.  Self-monitoring increases mindful awareness of the problem at hand, generates a record against which the effectiveness of the treatment can be measured, and can also result in behavior change if the self-monitoring is conducted real-time.  Individuals attempting to quit smoking who count the number of cigarettes they smoke as they smoke typically decrease their cigarette consumption by approximately 10%, even if they employ no other strategies for change.

Cognitive-behavior therapies generally employ four major strategies for change.  These including skills training, cognitive restructuring, exposure, and contingency management.  Skills training is appropriate when a problem exists because of skill deficit.  For example, some individuals may not have learned how to tolerate distress or regulate their emotions; therapy can directly teach such skills.  Cognitive restructuring involves identifying, testing out, and challenging thoughts and beliefs that might impede healthy functioning.  In cognitive restructuring, the role of the therapist is not to tell the patient that his or her beliefs are “irrational”, but rather to foster an attitude of empiricism on the part of the patient.  Unhelpful or irrational thoughts and beliefs are viewed as hypotheses to be tested via behavioral experiments.  For example, individuals with generalized anxiety disorder often have positive beliefs about worrying, such as, “Worrying prevents bad things from happening to me”.  Such a belief could be put to the test by freely worrying one week and limiting worry the next, while tracking the number of negative events that actually occur.  In exposure, patients act opposite of unjustified emotions, emotional that do not “fit the facts” of a given situation.  Gradual exposure to avoided situations, places, people, etc. changes problematic emotions that interfere with healthy behavior by promoting desensization and habituation.  Someone who knows how to relax but avoids it due to feelings of guilt or fears of “being unproductive” could practice attempting to relax in spite of these feelings, eventually quieting them.  In contingency management, problems in the environment are addressed, to ensure that the environmental rewards and punishments support healthier behavior.  Individuals in therapy can also learn how use positive reinforcement on themselves to become better at self-management.  A patient is openly taught to use these change strategies by practicing in session and via homework assignments in order to nudge the patient toward functioning ‘as their own therapist’, rather than fostering dependency on long-term therapy with the therapist.

CBT is intended to be efficient, short-term, and goal-oriented.  Sessions tend to be directed by the therapist and the mutually agreed upon goals for treatment.  CBT therapists encourage patients to form clear, behaviorally-defined goals for treatment.  Goals such as “I want to stop self-injuring” or “I want to be happier” are not considered to be optimal goals. The former does not suggest what the patient will be doing instead of self-injuring.  The latter does not define what happiness is, how the patient would know if she or she were happy, nor what thoughts and behaviors will become present/absent if the patient were to be happier. CBT sessions are structured. The CBT therapist and patient typically review homework, set a agenda for the remainder of the session, and then agree upon tasks for the patient to try in between sessions in order to hasten progress. CBT therapists are also transparent; they share their hypotheses openly with the patient, rather than analyzing in secret.

While different cognitive-behavior therapies share a common foundation, treatments for different disorders emphasize different techniques. CBT for depression emphasizes the restructuring of depressogenic thoughts/beliefs and scheduling positive activities. Treatments for anxiety disorders emphasize exposure. CBT for eating disorders emphasizes establishing regular eating and a meal plan, restoring weight (if necessary), exposure to feared foods, reducing body/weight checking and avoidance behaviors, and modifying self-esteem so as to decrease the over-evaluation of weight, shape, and the control of eating.

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John received a Bachelor of Science degree in Microbiology from the University of Wisconsin-Madison and a Master of Social Work degree from the George Warren Brown School of Social Work at Washington University in St. Louis.  His approach to treatment draws from cognitive-behavior therapies, such as dialectical behavior therapy and exposure and response prevention.  John attempts to help patients solve their problems with living and create a life with joy and meaning.  John believes that recovery involves purifying one’s motivation, learning more effective coping strategies, challenging unhelpful beliefs, facing one’s fears, and coaching loved ones to be more effectively supportive.