How does CBT treatment work?
CBT concentrates on helping you to identify, target and break your own specific unhelpful cycle in order to achieve reductions in your clinical symptoms and distress levels, whilst equips you with evidence-based (tried and tested!) cognitive and behavioural strategies for you to self-manage and prevent future setbacks.
The specific focus of your treatment will ultimately be determined by a combination of your clinical presentation, your specific treatment goals and the related Evidence-Based-Research. Whilst different clinical presentations utilise different types of interventions, a CBT treatment plan will always include the following core elements.
A central thread of any CBT treatment plan will be the ongoing measurement and evaluation of your symptoms and associated distress levels, which will always be directed by your specific treatment goals. Goals are identified at assessment during an exploration of your most problematic clinical symptoms, typically occurring scenarios and development of your problem list detailing your main clinical priorities. Your goals provide us with a focus for your treatment; influence which “direction” (life values) you want your journey (treatment process) to take, and include “the destinations” (specific areas for change) that you want to achieve during your journey – as these will provide the necessary steps to aid arrival at your intended destination (conclusion of treatment.)
I use SMART goals (Specific, Measurable; Achievable; Realistic and Time-based) as a template for establishing clear treatment goals. This template offers a method that can be set, reviewed and modified to capture each clients’ specific evidence of change, throughout treatment. Because this template requires a specific timeframe for each goal, I find that this can also help clients in the management of their own expectations and can aid a realistic pace during treatment, through consideration of short-term; mid-term and long-term goals. For example, one client’s short-term goal may be “within the next month” whilst another’s might be “within the same week.” Conversely, whilst one client’s long-term timeframe may be “within the next 6 months,” another’s’ might be “within one year.”
Just as patterns of thinking influence our emotions and behavioural responses, our behaviours will influence our thinking patterns and emotions. CBT treatment is focused on enabling clients to recognise, drop, and supplement their unhelpful maintaining behaviours for more favourable alternatives. Whilst developing a cognitive understanding of the underlying maintaining beliefs will be necessary, starting treatment with a behavioural focus can often help to provide clients with early coping skills to help manage their emotions from the beginning of therapy onwards.
In the treatment of depression, NICE guidelines recommend starting with a behavioural approach. Depressed clients frequently report significant global reductions in their activity levels along-with associated emotions of hopelessness and helplessness, as a by-product of their clinical symptoms of low mood; reduced energy levels and paucity of interest and pleasure experiences. Many will also report cognitive difficulties in the form of concentration, attention and memory, coupled with negative beliefs about themselves, others and the world around them. Ultimately, cognitive techniques will be necessary in treatment in order to target these negative cycles. For severely-depressed clients however, “accessing” their cognitive abilities – necessary to be able to understand, process and apply the cognitive treatment techniques – will prove extremely difficult. Therefore, treatment firstly needs to help these clients to activate their brain, to “switch-on” their cognitive abilities, to then be able to understand, retain and apply the subsequent cognitive techniques. By using behaviour to change behaviour via a combination of behavioural activation and activity scheduling components, CBT treatment for depression facilitates a depressed clients’ cognitive functioning by boosting their emotional and physical functioning.
By contrast, with anxiety disorders clients will often report an over-response in behaviour. For example, in the case of Obsessive-Compulsive-Disorder, clients will report severe and disabling compulsions, (behaviours, felt compelled to action following an emotional trigger) that prove exhausting due to the time spent; repetitively actioned and rigidly applied. A behavioural perspective in early treatment helps the client to improve their tolerance to their distress, typically through Exposure Response Prevention, and/or grounding techniques completed in session with therapist, prior to the introduction of a cognitive approach, to help them learn to tolerate a level of emotional discomfort that is “bearable.” In other words, providing important counter-evidence to challenge their previous beliefs associated with the emotion, or their coping abilities.
The cognitive element involved in treatment will always explore three levels of beliefs. Those that become activated in the here-and-now and are situation-specific (Negative Automatic Thoughts); those that exist at a mid-level subconscious awareness – often inferred by our actions – that capture our generalised Rules, Attitudes and Assumptions about ourselves, others and our wider environments. Finally, those that are centrally-held, (Core beliefs) that operate unconsciously, having developed in early childhood.
“Turning NATs into BATs”
Initial treatment sessions will often look to identify specific and/or most commonly reoccurring Negative Automatic Thoughts (NATs.) Doing so enables the identification of cognitive distortions (thinking errors) that you may be prone to making that will alter your perception and interpretation(s) of a situation. The “negative” emphasis that these automatic thoughts have, and the distorted or biased conclusions you then make in a situation, will directly-influence your emotions and behavioural responses. Over time, this leads to the development of negative maintaining cycles, that gather momentum following repeated activation, and maintain your clinical symptoms.
Following these discoveries, treatment will use cognitive challenging and reframing techniques to help you generate as many alternative angles (positive, negative and neutral) on the situation as possible. The more that are identified to provide equally-plausible interpretations, doubt can then be planted in relation to the reliability and credibility (accuracy) of your original belief/conclusion, offering flexibility in the form of a conscious choice as to whether you continue to hold your original belief, or choose to consciously-override it with one of your Balanced Alternative Thoughts (BATs) that you have identified instead.
Engaging with this process is fundamental to CBT treatment, regardless of the specific clinical presentation being treated. The alternative BATs you generate help to “take the emotional sting out” of your original NATs as they offer flexibility and doubt, reducing your physiological arousal sensations in your body and positively-influencing your emotional reactions – breaking the cycle.
“Challenging Rules; Attitudes and Assumptions”
This mid-level set of beliefs are often referred to as the “If… Then… , “ statements. They can be viewed as the emotional brain’s attempt at trying to assign a generalised rule, to help link two variables that originate from emotional experiences in childhood. They are mainly inferred by our behaviour(s) and develop during childhood, ultimately to provide a protective function; to protect our emotional equilibrium by preventing or reducing further exposure to the original trigger for the emotional discomfort.
For example, if a client has experienced absent, or inconsistent experiences of love and compassion in their early life, and/or experienced contrasting messages between parents (i.e. one may have demonstrated love, yet the other may have been emotionally-cold and focused on the child’s achievements) then the client may develop attitudes that others might be conditional in their love, or uncaring, which might influence a bottom-line core belief associated with “not being good enough.” These attitudes and assumptions will influence a client’s generalised rules (standards that they will try to meet in order to ensure they are protected from connecting with their bottom-line assumptions.) In consequence, a client with these early experiences could identify with a rule that sounded similar to “If… I work hard and hit my targets, Then… I will earn good money and gain my family’s respect.”
These beliefs originate from childhood and are ultimately governed by an emotional reaction to a situation, or series of situations. Because children lack the maturity, skill and life experience to be able to apply logic, these beliefs therefore take form based on emotional reasoning; the concept that “if something feels true, then it must be true.”
During treatment, these deeper-level beliefs often emerge in the form of reoccurring themes that become activated subsequent to a downward spiral of NATs, triggered in a specific situation. Treatment serves to test out the reliability of these deeply held beliefs, as their high level of associated emotional investment (often rated using a Belief Rating % value) will often create significant restrictions and disruption across multiple life domains, for the same client. (For example, impacting on their functioning at work; socially; at home and across their main relationships.)
Behavioural Experiments (specific, hypothesis-driven, activities) are devised by client and therapist to gather behavioural “real-life” evidence from the client’s life, designed with a clear belief in mind, to help identify and distinguish the factual evidence that exists within a specific situation, from the client’s felt-sense opinion. By examining the evidence that the client gathers and repeating the experiments across a number of the client’s life domains using a variety of methods, new counter-evidence gathered offers doubt and flexibility over the client’s original belief and investment. With this flexibility, comes newfound freedom and a conscious choice as to whether they want to continue to hold their original belief, or replace, update or amend it for one that is more workable.
“Amending Core Beliefs”
Core beliefs are considered by many to exist along a continuum, with a positive and negative polarity associated with each specific belief. For example “I am loveable,” and “I am un-loveable,” will both exist, hopefully with many more experiences falling towards the positive pole of the scale. These positive experiences will likely motivate and encourage a client, and therefore do not become a main therapeutic focus.
It is important to acknowledge that our core beliefs will have developed and gained emotional strength over the course of our lives; reinforced at times in adulthood when faced with situations that emotionally-resemble our early experiences.
Consequently, our core beliefs will detail years-worth of historical evidence, therefore it goes to follow that the process of un-learning the old and the cultivation of new will take both time and repeated behavioural action to bed down and take root. By acting as if you already believe, you believe. This process will start during treatment but continues long after sessions conclude.
Relapse Prevention – managing setbacks
Invariably, because of the automatic and habitual nature of each client’s experiences, in combination with the fact that life will continue to happen, it is to be expected that all clients will encounter a setback at a point in their future post therapy. With this in mind CBT therapy prepares to end, from the beginning. Sessions will consequently introduce the concept of relapse prevention through the development of a working document; a template that captures your own unique completed formulation “jigsaw puzzle” which you will be encouraged to keep and refer to, as an active ongoing resource.