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CBT

CBT is a highly effective strategy for dealing with many psychological prob-lems. In fact, CBT is at least as effective as medication for the problems that will be discussed in this book. Furthermore, CBT is not associated with any side effects, and can be practiced without any risks for an unlimited period of time. The goal of CBT is to change maladaptive ways of thinking and acting in order to improve psychological well-being. In this context, it is important to explain the term maladaptive. This goes to the heart of the definition of mental disorders. Psychiatrists and psychologists alike have been engaged in a long, heated, and still ongoing battle over the way to best define a mental disorder. Jerome Wakefield (1992) offered a popular contemporary definition of mental disorder. He defines it as a harmful dys-function. It is harmful because the problem has negative consequences for the person and also because the dysfunction is negatively viewed by society.

It is a dysfunction because having the problem means that the person cannot perform a natural function as designed by evolution (for a critical discus-sion, see McNally, 2011).

Some of the most extreme positions in this debate question whether mental disorders even exist. One of the earliest and most vocal proponents of this position was Thomas Szasz (1961). Szasz views psychiatric disorders as essentially arbitrary and manmade constructions formed by society with no clear empirical basis. He argues that psychological problems, such as depression, panic disorder, and schizophrenia, are simply labels attached to normal human experiences by society. The same experiences that are labeled as a disease in one culture or at one point in history may be considered normal or even desirable in another culture or at another point in history.

Proponents of CBT acknowledge that culture contributes to the expression of a disorder, but they disagree with the view that human suffering is simply a made-up construction by society. Instead, CBT conceptualizes psychiatric disorders as real human problems that can be treated with real human solutions. At the same time, CBT is critical of the excessive medicalization of human experiences. In CBT, it is not important whether or not a psychological problem that interferes with normal functioning is labeled as a psychiatric disease. The names of mental disorders come and go, and the criteria used to define a specific mental disorder are arbitrary and manmade. But human suffering, emotional distress, behavioral problems, and cognitive distortions are real. Regardless of what the name for the human suffering is—or whether there is even a name for it—CBT helps the affected person to understand and alleviate the suffering.

On the other extreme is the view that mental disorders are distinct medical entities. Psychoanalytically oriented clinicians believe that these disorders are rooted in deep-seated conflicts. Based on Freudian thinking, these conflicts are typically considered to result from repression (e.g., suppression) of unwanted thoughts, desires, impulses, feelings, or wishes. For example, the conflict in Joe might be considered to be rooted in his relationships with his mother or father, and his depressed mood might be seen as a result of anger toward them that is turned inward toward himself. More modern psycho-analysts, who often identify themselves as insight-oriented or psychodynamic psychotherapists, might place a greater emphasis on existing or unresolved interpersonal conflicts, compared to Freudian therapists, who focus on experiences during early childhood. For example, modern psychodynamic therapists might see Joe's depression as a result of unresolved grief from a lost relationship to a significant person, such as his father or mother. The problem with these ideas is that even after more than 100 years of psycho-analysis, there is almost no scientific support for them.

Instead of delving into the past to uncover any early parent-child relationship conflicts that might have caused the problem, CBT primarily focuses on the here and now, unless the past is clearly causing the present. For example, Joe's recent layoff, his previous attempts to deal with depression, and any events that happened in the past and that might have contributed to the present are important. However, unlike psychodynamic therapy, CBT is not based on a preconceived notion that Joe's current depression must be related to unresolved conflicts with his father, mother, or any other attachment figure, or that Joe's depression is an expression of an elusive energy that is turned against himself. Instead, CBT takes a scientific and exploratory approach in trying to understand human suffering. In doing so, the patient is seen as an expert who has the ability to change the problem, not as a helpless victim.

Biologically oriented psychiatrists believe that psychological disorders are biological entities. Proponents of this perspective believe that mental disorders are causally linked to particular biological factors, such as dysfunctions in certain brain regions and an imbalance of neurotransmitters.

GENERAL APPROACH OF CBT

Although CBT is a popular treatment method, there are a number of false beliefs (cognitive errors, if you will) concerning what (modern) CBT is all about. Contrary to popular belief, CBT does not mean that therapy is limited to cognitive modification. It simply means that identifying and modifying cognitive distortions are important goals of treatment, because CBT rests on the principle that cognitions are causally linked to emotional distress and behavioral problems. CBT also targets emotional experiences, physiological symptoms, and behaviors. Depending on the nature of the treatment strat-egy, Beck distinguishes between intellectual, experiential, and behavioral approaches, all of which are important aspects of CBT. As part of the intellectual approach, patients learn to identify their misconceptions, test the validity of their thoughts, and substitute them with more adaptive ideas.

The experiential approach helps patients to expose themselves to experiences in order to change these misconceptions. In Joe's case, the CBT therapist explored the reasons for his feelings of worthlessness and for his previous suicide attempts. An important treatment goal was to raise Joe's level of energy and motivation. This was initially accomplished by assigning Joe some simple and then more complex tasks to do during the day, ranging from mild physical exercise, household chores, and shopping, to sending out job applications, going to job interviews, and pursuing a hobby. The central element of the behavioral approach is to encourage the development of specific forms of behaviors to improve the patient's well-being. This assignment is often referred to as behavioral activation. It can break the cycle of negative thinking and low energy and motivation. Behavioral activation lifted Joe's energy, changed his self-perception, and improved his mood. Because of the strong emphasis on the behavioral aspects of many psychological problems, the term CBT appears to be more appropriate than only cognitive therapy or rational therapy, as it was initially referred to by the two founding fathers. CBT is primarily focused on the here and now. The patient is an active collaborator who is considered to be an expert on his or her psychological problems. The relationship between the therapist and patient is warm and genuine and the communication is direct but mutually respectful. The patient is not seen as deficient and the therapist is not seen as an omnipotent healer. Instead, the therapist and patient form a collaborative relationship in order to solve a problem. The initial role of a CBT therapist is typically very active as he or she educates the patient about the underlying principles of this treatment approach. However, as treatment progresses, patients are expected to become increasingly active in their own treatment, more proac-tive, and more independent.

Usually, patients seek help for a variety of different problems. A careful analysis often shows that the different problems are directly related to one another or that different sub-problems can be subsumed under one larger problem. For example, Joe's lack of motivation, low energy, and tendency to oversleep are clearly related to his overarching problem of depression and feelings of low self-worth. If CBT were to primarily target Joe's sleep prob-lems, it would obviously miss the main point of Joe's psychological problems.

It appears that Joe's feelings of low self-worth are the main problem that should be targeted in treatment. Some of Joe's core beliefs (schemas) were:

"I am worthless unless I can support my family," and "I am incompetent."

These core beliefs are typically more overt at a later stage in the treatment process, when it becomes apparent that the various automatic thoughts share certain commonalities. This process requires careful self-exploration by the patient and guided questioning (or guided discovery) by the therapist (which has been referred to as a Socratic questioning style in Beckian CBT). As therapy progresses, the goals of CBT become more focused and oriented toward the patient's core beliefs. However, these goals are not determined by one person alone. Throughout the treatment process, the therapist and patient frequently revisit the goals of therapy, including identifying the types of interventions that will be most effective for reaching these goals and delineating concrete observable outcomes that will indicate that each goal has been achieved. Patients are fully involved in these decision-making processes.

There is a common misconception that CBT replaces negative thinking with positive thinking, which will then miraculously solve all psychological problems. This is incorrect on several levels. CBT cannot and should not attempt to make a bad situation good. CBT does not encourage patients to think positively about realistically distressing events or to ignore a tragedy that has happened to them. Rather, the CBT therapist helps the patient to critically examine whether his or her response to a situation is justified.

Establishing good therapeutic relationships

Positive therapist-patient interactions flow from a collaborative relationship.

In general, therapists' behavior should be honest and warm. Patients are not considered to be helpless and passive but, rather, experts of their own prob-lems. Therefore, patients are actively involved in treatment. For example, they are encouraged to formulate and test certain hypotheses in order to gain a better understanding of the real world and their own problems. The emphasis during therapy is placed on solving problems. The therapist's role is to work with the patient to find adaptive solutions to solvable problems.

Every step in therapy is transparent and clearly reasoned. Patients are encouraged to ask questions to ensure that they understand and agree with the treatment approach.

The initial role of the CBT therapist is very active. Therapists should educate patients about the underlying principles of this treatment approach.

In addition, therapists often find that patients need a great deal of guidance in the beginning stages of therapy in order to help them successfully identify their misconceptions and the associated automatic thoughts. As treatment progresses, patients are expected to become increasingly active in their own treatment. A masterful CBT therapist reinforces his or her patient's independence while at the same time being aware of the need for continued support and education as patients first begin to apply the concepts of CBT to their difficulties.

PROBLEM FOCUS

CBT is a problem-solving process. This process includes clarifying the status of the presenting problem, defining the desired goal, and finding the means to reach that goal. Therefore, the therapist and patient discuss the goals of therapy at the beginning of treatment, including identifying the type of interventions that are to be used to reach these goals and delineating con-crete, observable outcomes that indicate that each goal has been achieved.

CBT case formulation can facilitate this step. The goal of a formulation-based assessment is to identify core beliefs that underlie misconceptions and associated automatic thoughts in order to intervene effectively during treatment.

Through the process of problem reduction, therapist and patient then identify problems with similar causes and group them together. Once the major problem is identified, the therapist typically breaks it up into component problems to be attacked in a given case. Therapists frequently elicit feedback from the patient throughout treatment to ensure that problem-solving efforts are on target with identified goals.

Identifying Maladaptive cognition

Once patients define their problems and goals for treatment, CBT therapists encourage them to become aware of their thoughts and thought processes.

As discussed in Chapter 1, cognitions are generally classified into negative automatic thoughts and maladaptive (sometimes also referred to as dysfunctional or irrational) beliefs. Negative automatic thoughts are thoughts or images which occur in specific situations when an individual feels threatened in some way. Maladaptive core beliefs, on the other hand, are assumptions that individuals have about the world, the future, and themselves. These more global, overarching core beliefs provide a schema that determines how a person may interpret a specific situation. Just as with automatic thoughts, therapists can identify maladaptive core beliefs through the process of guided questioning.

Challenging Maldataptive cognition

By treating maladaptive cognitions as hypotheses, patients are put into the role of observers-scientists or detectives—rather than victims of their con-cerns. In order to challenge these thoughts, therapist and patient discuss the evidence for and against a particular assumption in a debate, engaging in what Beck calls Socratic dialogue. This can be done in a variety of ways, typically by using information from patients' past experiences, empirically evaluating a situation, evaluating the outcome of a situation, and giving patients the opportunity to test their hypothesis by exposing them to feared and/or avoided activities or situations.

At first, patients are often asked to generate rational alternatives to their irrational responses to a challenging situation. As this skill is polished, patients are encouraged to use their skills both before and during difficult