Treatment
What is CBT?
Cognitive-Behavioral Therapy (CBT) is a form of psychotherapy that emphasizes the importance of thinking in determining how we feel and act. CBT is really an approach, rather than a single, specific treatment, and there are many different treatment approaches and techniques that full under the rubric of CBT.
Various names that you might hear that fall under the umbrella of CBT include Acceptance and Commitment Therapy (ACT), Mindfulness-Based Cognitive Therapy (MBCT) Meta-Cognitive therapy (MCT), and Rational-Emotive Therapy (RET).
All of the various CBT approaches share many things in common. Treatment is short-term, goal-oriented, and systematic. One of the central components to all CBT approaches is to work with clients to help them to reduce their symptoms and achieve more flexibility in their thinking, emotions and behaviors. There are a number of specific techniques that we use to achieve this goal, but the focus is on understanding and changing the inter-relationships among thoughts, emotions, and behaviors.
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How does CBT work?
From a CBT perspective, the problems that people bring to therapy result from an interaction among biology (inherited temperament and characteristics as well as developmental effects), learning history (the sum total of life experiences), and current situation (what is happening right now in their lives). As a result of these factors, people develop specific styles of thinking, feeling and acting that may not be productive for them and may lead to frustration, unhappiness or a host of specific symptoms such as anxiety and depression. CBT can help you to change your style of thinking, feeling, or acting, so that you have more flexibility in how you experience your world and are thereby less likely to feel controlled by your emotions and better able to live the life that you desire.
Recent research shows that changes that result from CBT may result in permanent changes in your brain function and chemistry. Thus, the changes that you make may be hard-wired, in much the same way that learning any skill (e.g., playing a musical instrument) can lead to permanent changes in your brain.
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What will treatment be like?
CBT is a structured and goal-oriented approach. The first session or two will be devoted to an evaluation and formation of a treatment plan. The evaluation consists of an interview and may include some simple self-report paper and pencil measures. Although I need to collect detailed information about the history of your problem, as well as aspects of your developmental history, I don’t spend a lot of time exploring issues from long ago because treatment focuses on changing current patterns, rather than simply trying to figure out how they began.
At the end of the evaluation, I will share with you my view of your problem and how treatment can help. We will then work together to develop clearly stated goals for treatment to ensure that your expectations and what I am offering are closely aligned. After the initial visit (usually 90 minutes) we typically meet weekly for 50 minutes sessions. A specific agenda is mutually agreed upon at the beginning of each session that is based on your goals as well as your progress in therapy.
A central aspect of CBT is the use of homework assignments—some involve reading or writing, others involve doing some specific task. These assignments are focused on real-life application of the techniques that are learned in therapy. A major focus of each treatment session is to review the results of completed homework assignments and discuss what was learned and how future assignments can be best structured.
During the course of treatment, we will continuously assess how you and I view your progress and whether treatment is meeting your expectations. Treatment is a collaborative process between patient and therapist, and it works best when we both share a view of the work that has been completed and what is left to accomplish.
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How long will treatment last?
CBT is short-term therapy, relative to other therapies that can last for several years (e.g., psychoanalytic therapy). Most clients see some improvement relatively quickly and an average course of therapy is in the range of 10 – 20 sessions. However, there is no set number of sessions because treatment is tailored to each unique individual case. I work collaboratively with each client to identify primary complaints, set specific treatment goals, and to track progress toward goals. As treatment progresses, adjustments are made to ensure that you receive treatment that is optimized for your specific concerns.
The frequency of treatment sessions may change across time, beginning with weekly sessions and moving to bi-weekly, monthly or less frequently as progress is made. Many patients continue to meet with me intermittently over a long term to prevent relapse and to maintain their gains. It is said that the CBT therapist has many roles, beginning with therapist and evolving to teacher, coach, advisor and, finally, consultant. We will collaborate on the evolution of the relationship and how it is ultimately structured.
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Will I need medicine?
As a Clinical Psychologist, I do not prescribe medicine. However, we have several psychiatrists on staff that can evaluate you and provide medicine, if needed. We will decide, together, whether a consultation for medicine is warranted. If you do receive medicine from one of our psychiatrists, I will work closely with him so that we are both in agreement about your treatment plan and your progress.
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Treatment for anxiety disorders
There are several well-established CBT approaches for treating anxiety disorders. Although the focus of treatment and specific techniques employed vary somewhat across the different disorders (e.g., treatment for panic disorders differs from treatment for obsessive-compulsive disorder or generalized anxiety disorder) several aspects of treatment are consistent across the anxiety disorders spectrum.
Two key concepts for understanding CBT for anxiety disorders are: a) experiential avoidance, and b) exposure. Experiential avoidance (sometimes described as fear of fear) is the attempt to avoid specific thoughts and feelings that are uncomfortable. Panic disorder provides a good example of how experiential avoidance can develop and be maintained.
Clients often report that panic attacks are so uncomfortable that they will do almost anything to avoid having them. As a result, situations and activities associated with panic attacks may be studiously avoided. Avoidance works in the short-term because it keeps you out of situations where you might feel anxious, and the avoidance behavior is thereby strengthened (maintained by negative reinforcement). When avoidance becomes extreme, clients are diagnosed with agoraphobia.
Exposure is a treatment approach that provides contact with the feared object, situation, or thought that is causing distress. A classic CBT approach is to develop a hierarchy of feared situations, teach some coping and distress management skills, and to encourage gradual exposure to the hierarchy via a set of structured behavioral exercises. One goal of exposure exercises is for clients to learn that anxiety is not really dangerous (although it is uncomfortable) and that they can learn to function even with anxiety. A further goal of exposure is habituation to anxiety, so that the intensity of symptoms is reduced, gradually, across time.
CBT also uses a variety of techniques for “restructuring” cognitions. What this means is helping you change the way that you think. Some of these techniques approach thinking directly, and we often spend time talking about how strongly beliefs are held, discussing the evidence base for beliefs, generating alternative explanations, as well as conducting mini experiments to test beliefs.
Exposure also has an impact on beliefs. Learning that you can function in feared situations and that no irreparable harm occurs, results in a revised perception of the things that you fear. Maybe they are not as dangerous or terrifying as you once believed.
Some of the newer CBT approaches incorporate “mindfulness” and “acceptance” based techniques. These techniques also use exposure type exercises, but they differ somewhat from the classic CBT approach by teaching that the experience of anxiety, although it may be uncomfortable, does not necessarily need to be reduced in order for clients to live happy, fulfilled lives. Thus, there is more of an emphasis on re-interpreting or “deconstructing” anxiety as a normal part of everyday life, and less of an emphasis on attempts to reduce specific symptoms. We talk about helping clients change their “relationship with their thoughts.”
An important aspect of this approach is learning to recognize, understand, and manage “metacognitions.” The term Metacognition refers to thoughts about thoughts and styles of thinking and processing information. What does it mean if you have fears and anxieties? Consider a person who experiences a rapid heart rate in a social situation and has the thought “I acted like an idiot; I am so embarrassed.” If the symptom and the thought are simply dismissed as something that happened and no big deal, the event is unlikely to be remembered and unlikely to cause significant distress. If, however, the event results in a focus on figuring out “what is wrong,” and attempts to prevent it from happening again, it may be an early step in the development of social anxiety disorder.
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Treatment for obsessive-compulsive disorder
Cognitive-behavioral treatment of obsessive-compulsive disorder (OCD) is referred to as exposure with response (or ritual) prevention (ERP). Obsessions are thoughts, often related to some specific fear (e.g., fear of contamination by germs or fear for the health of a loved one), and rituals are behavioral or mental acts that serve to reduce the anxiety generated by the obsessions. The goal here, as with treatment for other anxiety disorders, is to induce clients to remain in contact with the feared object/situation/context or uncomfortable thought and to not engage in any rituals that will reduce the anxiety. Over time, anxiety will diminish naturally and the OCD will weaken, making it easier for clients to function, even if some low-level symptoms remain.
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Treatment for depression
Depression is a complex disorder composed of a tightly-linked pattern of thoughts, feelings, and behaviors. Many years ago Aaron Beck identified the “cognitive triad” that is characteristic of depressive thinking: negative thoughts about the self, the world, and the future. However, thinking is not the whole story. As depression becomes chronic, the link between thinking, feeling, and behavior becomes ever stronger and difficulties in any one area can trigger the entire syndrome. Treatment focuses on breaking the links among thoughts, feelings, and behaviors, thereby changing the underlying pattern. I will work with you to determine the most efficient and effective way to approach your depression. In some cases we will focus initially on changing thoughts; in other cases we will focus on behavior first (e.g., increasing activity) and observe how thoughts and feelings change as a result.
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Treatment for stress disorders
Treatment for stress disorders involves a combination of problem-solving strategies and learning how to think about situations in a different way. I will help you to identify clearly the stressors in your life and to formulate an approach to cope with them more effectively. In some cases, we will focus on changing situations that are causing distress (e.g., by learning how to be more assertive). In other cases situations may not be changeable (e.g., dealing with a chronic illness), and we will focus on working with your thoughts and reactions to the situation.