HELP TOPIC
COGNITIVE BEHAVIORAL THERAPY
Cognitive behavioral therapy is one of the best-researched therapeutic approaches, and its effectiveness has been confirmed by numerous clinical studies. Its origins date back to the 1960s, when the American psychiatrist Aaron Beck successfully began using his cognitive therapy for depression. Beck’s method, which points to the crucial importance of negative beliefs about oneself, the world, and other people in the development of depression, became a source of inspiration for creating cognitive models of other mental disorders and a form of therapy based on changing maladaptive beliefs.
Key assumptions
The cognitive-behavioral approach is based on the assumption that thoughts, emotions, and behavior are interconnected. By assigning meaning to the situations and experiences a person encounters, that person creates an individual view of the world. Incoming information is automatically reinforced or rejected, depending on whether it fits your belief system or your current state. As a result, the same situation can be interpreted in completely different ways by two different people. For example, a depressed person who is driving may focus on red lights and traffic jams and become convinced that he always hits every red light and that the world is always against him. Naturally, this will only make him more depressed and anxious. On the same route, a positive person may mainly notice green lights and enjoy a smooth drive. The meaning assigned to the situation influences which emotions a person experiences and which actions he or she takes.
The essence of cognitive behavioral therapy is therefore to identify, challenge, and modify negative, incomplete, distorted, or exaggerated interpretations. According to the cognitive-behavioral approach, these interpretations form the basis of the problem. By changing our maladaptive thoughts and interpretations, we can change the maladaptive behavior that results from them. This therapy is successfully used in the treatment of depression and anxiety disorders.
A form of therapy
Cognitive behavioral therapy focuses on the present and on finding solutions to current problems. It usually lasts from 6 weeks to 6 months. Throughout the therapy, a picture of the patient’s problem is developed dynamically, allowing the most effective actions to be continually adjusted. During the session, the patient’s problem is broken down into five components that mutually influence one another, and the following elements are discussed: the specific situation, the characteristic way of thinking that occurs in that situation, the emotions and physical sensations that such thinking triggers, and the action that results from the preceding factors. Thanks to this approach to the problem, it is possible to analyze the individual elements in terms of their rationality and logic and to learn about their mutual influence on one another.
During the session, maladaptive thoughts are examined (the cognitive element of the therapy), after which their rationality is questioned and more helpful alternatives are sought. In the above example, the same situation could trigger a positive thought: “But Janek seemed to be deep in thought; he walked right past and did not even notice me!” This thought can create amusement (emotions) and encourage you to contact Janek (behavior) to make him aware of his behavior and ask how he is doing. A positive thought, unlike a maladaptive one, can help renew and strengthen contact with a friend.
Therapy often begins with changing behavior and creating new healthy habits (the behavioral element of the therapy). The patient is encouraged to carry out behavioral experiments in which they have the opportunity to test their own beliefs by trying out new behaviors and new reactions. In the above example, the therapist and the patient can simulate this situation, starting with a behavioral change: the patient calls a friend to explain the event. Then they consider what thoughts could lead to such a reaction and what the consequences of that would be. Throughout the therapy, cognitive and behavioral elements are intertwined and complement each other.
Causes of conditions
The source of the disorder is a maladaptive way of thinking, i.e., a way of thinking that influences the emergence of unpleasant emotions, physical sensations, and inappropriate reactions. A negative interpretation of current experiences may be the result of a person’s current state of well-being, for example depression or nervousness. It may also be the result of established cognitive patterns relating to one’s image of oneself, the world, and other people.
Schemas are a set of beliefs that form a filter for incoming information: elements that fit the schema are accepted, while elements that do not fit are rejected. Someone who sees themselves as ‘unlikable’ will interpret the situations they encounter through this filter. For example, if that person runs into a female friend on the street who does not notice her, she may assume that she was being deliberately ignored, while there may be many objective reasons, such as the friend being distracted. In this way, maladaptive patterns and the resulting emotions and behaviors are maintained, which contributes to the persistence of the problem.
Limitations
The results of research into the long-term effects of cognitive behavioral therapy are inconclusive. Although this therapy can help you get rid of distressing complaints and symptoms in a short period of time, it does not address the psychological basis of the problem. As a result, the same unresolved underlying problem may reveal itself after some time in the form of different external symptoms. Therapy requires the patient to gain insight into his or her own thoughts, emotions, and hidden assumptions. It is largely based on the patient’s own efforts, including being assigned ‘homework.’ The homework assignments, on which the effectiveness of the therapy largely depends, may be rejected or neglected by the patient, especially if the therapist does not explain their purpose and does not clearly relate them to the patient’s problems. Achieving genuine and lasting results takes time and practice. Challenging negative thoughts and seeking adaptive alternatives while in a state of depression or severe anxiety may be too great a challenge for the patient.
Therapy methods
Cognitive behavioral therapy uses many complementary cognitive and behavioral techniques. According to the generally applied principle, “the greater the dysfunction, the more behavioral techniques are used; as the patient’s condition improves, cognitive techniques are used more often.” A good relationship between therapist and patient is crucial to the effectiveness of the therapy as a whole and of the individual techniques.
Among the cognitive techniques, Socratic dialogue is the most basic and oldest technique. Its goal is to reach the problem areas in the patient’s cognitive system, uncover biases in thinking, and develop new ways of thinking to test reality. The therapist uses Socratic dialogue: through a series of questions, the therapist leads the patient to discover the beliefs and assumptions underlying automatic thoughts. The therapist asks questions, listens empathically, and summarizes the patient’s statements, but does not offer personal opinions or give advice. Particular attention is paid to emerging contradictions, and the patient is asked to explain them. By encouraging details, explanations, and reflection, the therapist leads the patient to formulate new conclusions and solutions. Socratic dialogue also includes elements of other cognitive techniques, such as clarification, inquiry, paradox, and others.
Paradox and exaggeration can cause rapid changes in thinking. However, their effectiveness in identifying and modifying cognitive distortions depends on the therapeutic relationship and both parties’ sense of humor.
To interrupt the flood of automatic thoughts, distraction and shifting attention are often used. This technique is frequently used, among other things, in the treatment of schizophrenia. Interruption can be achieved through a sudden, intense stimulus, such as clapping. The thoughts must then be redirected to a task that requires attention, for example mentally subtracting the number six each time, starting from one hundred.
By recording thoughts, the patient can get to know themselves better—discovering under the influence of which thoughts they develop unpleasant emotional reactions and maladaptive behavior in specific situations. At the same time, the patient looks for alternative interpretations instead of maladaptive automatic thoughts.
By using the principles of conditioning and modeling that underlie the learning process, the patient learns the possible consequences of behavioral change and creates new beneficial responses and adaptive habits. In cognitive behavioral therapy, the patient learns to recognize negative thoughts and the underlying assumptions, verify them, and respond to them appropriately. The patient’s tasks, which consist of testing the truthfulness of their beliefs, assumptions, and expectations and gaining new experiences, continue beyond the session and are arranged by level of difficulty in such a way that they end successfully. Disproving hypotheses is the source of success and breaks the vicious circle of interdependence among thoughts, emotions, and behavior.
Cognitive behavioral therapy also uses stress inoculation training, aimed at changing the patient’s automatic self-statements in order to change their approach to stressful situations. Next, the impact of the internal dialogue on the patient’s behavior is discussed, and the content of new and more adaptive statements to be used in stressful situations is determined. In the next phase, the acquisition of new skills, the patient learns to use these established statements under stressful circumstances. The final phase is the transfer of stress-management skills acquired during therapeutic sessions to real-life stressful situations outside the therapy room.
Strengths
Cognitive behavioral therapy strongly develops the patient’s self-awareness. By becoming aware of the mutual influence of thoughts, emotions, and behavior, patients develop a sense of freedom of choice and control. The patient is equipped with tools and techniques that can be used both outside therapy and after it has ended to address problems independently and prevent relapse. As a result of identifying maladaptive thoughts and replacing them with more adaptive beliefs, self-esteem and motivation to take action also increase. Techniques for identifying and interrupting negative thoughts are also used as supportive methods in other therapeutic approaches. Most group therapies are based on cognitive-behavioral techniques.
This type of therapy is effective in the treatment of various forms of depression and anxiety disorders (including in children), post-traumatic stress disorder, social phobia, panic attacks, and obsessive-compulsive disorder. Cognitive behavioral therapy produces better results in treating the symptoms of bulimia than pharmacotherapy. It is also effective in the treatment of psychosomatic disorders. In addition, this therapy can be successfully applied in coping with stress or in the rehabilitation of criminals. It also produces good results in reducing depressive and anxiety symptoms associated with premenstrual syndrome and in the treatment of perinatal depression.
ISSUES
TYPES OF THERAPY
Dialectical behavior therapy (DBT)
GGZ voor elkaar in Utrecht is a healthcare institution that brings together some of the best specialists in mental health care in the Netherlands. Our team members specialize in various treatment methods. The main methods used at our institution include the following.
Cognitive behavioral therapy
Cognitive behavioral therapy is one of the best-researched therapeutic approaches, the effectiveness of which has been confirmed by numerous clinical studies. Its origins date back to the 1960s, when the American psychiatrist Aaron Beck successfully began using his cognitive therapy for depression. Beck's method, which points to the crucial importance of negative beliefs about oneself, the world, and other people in the development of depression, has become a source of inspiration for creating cognitive models of other mental disorders and a form of therapy based on changing maladaptive beliefs.
Eye movement desensitization and reprocessing (EMDR)
It has already been a quarter of a century since the world first heard about this method for overcoming anxiety. To date, more than 2 million people have used the method successfully. The effectiveness of EMDR in people with both minor and major trauma has been clinically proven. When we use the word TRAUMA, we mean the psychological consequences of a negative experience that causes disorganization and dysregulation of the human physiological system.
Mentalization-based therapy (MBT)
Mentalizing refers to our ability to understand mental states—our own and those of others. We mentalize when we try to understand our own behavior and that of others in the context of intentions and other internal states. Focusing on this specifically human capacity, and treating it as an instrument for therapeutic intervention, forms the basis of mentalization-based therapy. MBT was initially developed for working with patients with borderline personality disorder (BPD), but is currently used across a broader spectrum of disorders (for example, antisocial personality disorders, family therapy, and adolescent therapy).
Dynamic interpersonal therapy (DIT)
Dynamic interpersonal therapy (DIT) is a straightforward short-term (16 sessions) individual treatment protocol for mood disorders. The protocol was developed based on the work of an expert reference group in the field of clinical competencies, which worked on identifying key elements from psychoanalytic/dynamic therapies. This is an easy-to-follow, semi-structured treatment protocol. This protocol for short-term dynamic work is intended to be implemented nationwide as part of the IAPT program for working with patients with depression, and therefore DIT training is supported by IAPT.
Psychodynamic psychotherapy
Psychodynamic therapy is a child of psychoanalysis, but it forms a separate approach due to numerous adaptations that distinguish it from the original. As the name suggests, psychodynamic therapy focuses.
IPT (Interpersonal Therapy)
Interpersonal Therapy (IPT) is a form of psychotherapy that focuses on improving the quality of interpersonal relationships and addressing problems that contribute to mental health complaints. IPT has proven particularly effective in the treatment of depression and other mood disorders, but can also be useful for other mental health conditions. Below is a detailed description of IPT.
Mindfulness
Mindfulness, or focused awareness, is a mental method in which you direct your full attention to the present moment, without judgment. It involves consciously experiencing what is happening right now, both within yourself (your thoughts, feelings, physical sensations) and around you (your surroundings and events). By practicing mindfulness, you learn to approach your everyday experiences with greater awareness and acceptance.
Exposure therapy
Exposure therapy is an evidence-based treatment technique that is used to treat anxiety and avoidance problems. The goal of this therapy is to help people reduce their fearful or stressful responses to certain situations, objects, or thoughts through gradual and controlled exposure to these fears. Exposure therapy is often used in the treatment of anxiety disorders, such as phobias, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and social anxiety disorder.