Cognitive Behavior Therapy for Depression and Anxiety
Modern cognitive behavioral therapy (CBT) was developed independently by two separate individuals: Albert Ellis, a clinical psychologist began his first version of what has become REBT in the early 1950s and Aaron Beck, a psychiatrist, began working on his version of the therapy (CT) in and around the mid-60s. Both versions of the therapy are founded on the single basic idea that cognition, in the form of thoughts and preconceived judgments, precedes and determines people's emotional responses. In other words, what people think about an event that has occurred determines how they will feel about that event. Depression happens because people develop a disposition to view situations and circumstances in habitually negative and biased ways, leading them to habitually experience negative feelings and emotions as a result.
More specifically, Cognitive-Behavioral (CBT) therapists suggest that depression is caused by a combination of an unhelpful dysfunctional thought process and by maladaptive behaviors motivated by that thought process. Because these dysfunctional thoughts and behaviors are learned, people with depression can also learn new, more adaptive skills that raise their mood and increase their ability to cope with daily hassles and stressors. Another basic idea behind CBT is that if a person changes their thoughts and behavior, a positive change in mood will follow.
The cognitive aspect of CBT involves learning to identify distorted patterns of thinking and forming judgments. These maladaptive thought patterns are also known as negative or maladaptive schemas, or core beliefs. Core beliefs are fundamental assumptions people have made that influence how they view the world and themselves. People get so used to thinking in these core ways that they stop noticing them or questioning them. Simply put, core beliefs are the unquestioned background themes that govern depressed people's perceptions. For example, a depressed person might think "I am unlovable" or "I am inadequate and inferior" and because these beliefs are unquestioned, they are acted upon as though they are real and true.
Core beliefs serve as a filter through which people see the world. Core beliefs influence the development of "intermediate beliefs", which are related attitudes, rules and assumptions that follow from core beliefs. When depressed people's core beliefs are negative and unrealistic, they lead people to experience predominately negative and unrealistic thoughts. Following along with the example started above, our depressed person might develop the attitude that, "It's terrible to be unloved". Similarly, the intermediate belief might include the following rule, "I must please everyone" and an assumption to the effect that, "If I please everyone then people will love me."
Intermediate beliefs can influence people's view of a particular situation by generating "automatic thoughts," the actual thoughts or images that people experience flitting through their minds. Automatic thoughts are evaluative cognitions which occur in response to a particular situation. They are spontaneous (hence the term automatic), rather than the result of deliberate extended thinking or the logical reasoning that occurs when someone concentrates.
Automatic thoughts occur effortlessly, more or less all the time. Most of the time we are unaware that they are occurring, not because they are unconscious sorts of things but rather because we're so used to them that we don't notice them anymore. Automatic thoughts influence emotions and behaviors and can provoke physiological responses. To continue the above example, if a friend of our depressed person does not return a phone call, our depressed person might think, "He's not calling me back because he hates me". It may never occur to her to generate alternative and less irrational explanations for the lack of a callback such as,"He must be really busy today." Because the automatic thought "he hates me" is allowed to stand unchallenged, our depressed person starts feeling hated, and thus depressed.
Though every patient's automatic thoughts are unique, there are also clear patterns of depressive automatic thoughts that are common across many depressed people's minds. Some common patterns of negative and irrational automatic thoughts include:
Catastrophizing – always anticipating the worst possible outcome to occur (e.g., expecting to be criticized or fired when the boss calls). Filtering – exaggerating the negative and minimizing the positive aspects of an experience (e.g., focusing on all the extra work that went into a promotion rather than on how nice it is to have the promotion). Personalizing – automatically accepting blame when something bad occurs even when you had nothing to do with the cause of the negative event (e.g., He didn't return my phone call because I am a terrible friend or a boring person; I caused him to not call.).
(Over)Generalizing – viewing isolated troubling events as evidence that all following events will become troubled (e.g., having one bad day means that the entire week is ruined). Polarizing – viewing situations in black or white (all bad or all good) terms rather than looking for the shades of gray (e.g., "I missed two questions on my exam, therefore I am stupid", instead of "I need to study harder next time, but hey – I did pretty good anyway!").
Emotionalizing – allowing feelings about an event to override logical evaluation of the events that occurred during the event. (e.g., I feel so stupid that it's obvious that I'm a stupid person).
Dysfunctional beliefs are thinking habits that people learn which happen to be irrational and not based on reality (e.g., on objective, unbiased observation). Because such beliefs are not linked to reality very well, they tend to appear rather distorted when compared with reality. Distorted though they may be, dysfunctional beliefs are all people typically have to help them make sense out of the events that happen to them. Snap judgments are made (called Cognitive Appraisals) based on the assumptions present within dysfunctional beliefs, and those judgments end up being, not surprisingly, biased and irrational. People look to their appraisals of stressful situations to know how to react, and when they do, they see that situations look simply awful (worse than it really would appear if some reality testing were to occur). They react to that false or exaggerated sense of awfulness, and correspondingly experience depressive symptoms.
Daniel Araoz, a leading researcher and theorist concerning hypnosis, says that this constitutes negative self-hypnosis.
A more concrete example of how CBT works may help. A therapist using Albert Ellis' techniques will help a depressed person to understand the chain of events that leads them to become depressed in terms of multiple steps occurring in sequence. For ease of remembering, these steps are identified by the first letters of the alphabet: A, B, C, D, and E.
In Ellis' scheme the "A" stands for Activating experiences, such as interpersonal relationship problems, work stresses or dissatisfaction, memories of early childhood traumas, and other situations that a person views as immediate sources of unhappiness. The "B" stands for the irrational, self-defeating Beliefs that are causing someone's unhappiness. The "C" stands for Consequences, which are the depressive symptoms and negative emotions that result from unhelpful beliefs.
Although the activating experiences may have been traumatic or painful, the cognitive therapist will point out that people's irrational beliefs actually create their depressed mood. In other words, it is people's reactions to situations, rather than the situations themselves, that cause problems. During therapy sessions, cognitive therapists will teach patients how to Dispute (e.g., the "D" step) the irrational beliefs, so that they may develop positive psychological Effects (the "E" step) of rational beliefs. Though the above ABCDE scheme is due to Ellis, a therapist working according to Aaron Beck's version of CBT would teach essentially the same procedure.
Cognitive behavioral therapists teach their patients to identify debate and then correct their irrational ideas. The disputing process involves teaching patients to systematically ask and answer a set of questions designed to draw out whether particular ideas have any basis. Examples of disputing questions include:
Is there any evidence for this belief? What is the evidence against this belief? What is the worst that can happen if you give up this belief? What is the best that can happen? After multiple sessions of CBT training, patients learn to monitor their own thoughts and perform the disputing process on their own outside of therapy sessions.
To continue with our example, the cognitive therapist would take an automatic thought generated by our depressed person such as "everyone hates me", and help her to examine the basis of that thought. The therapist might ask the patient whether it is literally true that no one loves her, encourage her to list examples of people who love or like her, and point out that thinking she is completely unlovable is erroneous and therefore should not be taken seriously.
The behavioral aspect of CBT involves replacing behaviors that are contributing to patients' depression with healthier ones. CBT therapists determine whether patients' behaviors are problematic or if they appear to have skill or coping deficits. Therapists then recommend alternative behaviors as appropriate, and educate patients in missing skill sets.
For example, participation in exercise, hobbies and social activities, as well as regular use of breathing, relaxation or visual imagery techniques can help decrease depression. Knowing this, a CBT therapist may encourage socialization or exercise for patients who have become withdrawn. CBT therapists may also use other techniques including role-playing (practicing new behaviors in session), prescription risk-taking activities (practicing new behaviors outside the therapy session), assertiveness training, and so on to help patients to improve.
CBT patients are prescribed homework throughout the course of their therapy. Homework assignments generally consist of instructions to keep a log of thoughts, behaviors, and moods, as well as written records of their efforts towards practicing cognitive restructuring exercises. Clients also note changes that occur as they try out new thinking or behavior skills, or fall back into old thinking habits.
As negative patterns become clearer, patients can experiment by trying out new skills and seeing (by looking at their logs and homework assignments) how these changes positively impact their mood.Along with reducing the number of negative thoughts and behaviors, CBT therapists also help depressed people to learn how to break complex and seemingly insurmountable tasks into smaller, more manageable components (as doing so increases their likelihood for achieving success).
For example, if cooking an entire meal seems overwhelming to a depressed person, then that depressed person might be encouraged to do whatever part of that larger task she can manage. She can, for instance, take pride in making one course of the meal on a given day. Teaching depressed people to take control of their negative anticipations and fears surrounding tasks (by disputing them or breaking them down into small manageable parts) can help decrease patients' avoidance and anxiety, and result in more rewarding success experiences which increase mood, and fuel patients' desire and self-confidence for attempting new tasks.
Cognitive behavioral therapy is offered in both individual and group formats, and in both outpatient and inpatient settings. Research-based therapy protocols typically last between 12 and 16 weeks in duration (assuming weekly therapy appointments); however, the therapy can be tailored (e.g., by increasing or decreasing the frequency and number of sessions) to fit patients' needs.
Cognitive behavioral therapy is a good fit for verbal, goal-oriented people who want short-term, symptom-focused strategies. CBT requires that people commit to monitoring and practicing skills outside the therapy session. CBT is less of a good fit for people who have trouble with metacognition (e.g., people who have difficulty thinking about their own thinking process), who are put off by Socratic-style questioning (logical debate and argument used to examine the appropriateness and validity of thoughts), who are interested in a less directive therapist, or who are unwilling to monitor their thinking, behavior, and feelings outside of therapy sessions.
The competent therapist will use CBT/REBT as a major component, yet have other tools at her disposal: Hypnosis, Transactional Analysis, Somatic tools have a part to play depending on the needs of the client/patient.