Cognitive Behavioural Therapy (CBT) is perhaps the most researched therapeutic approach over the last half Century. It has the advantage of being able to be broken down into brief discrete strategies and used in opportunistic moments, of being effective in addressing a wide range of mental conditions, and being especially effective with depression, anxiety, and addictions. Perhaps even more importantly, it can be effective when the client/patient (‘client’) is using prescription medicine and/or is, as is often the case, affected by more than one condition.

CBT is an intervention strategy that works in conjunction with other therapies, such as the widely used Motivational Interviewing (MI) approach, and to emphasise this, several tools are shared by CBT and MI. Although the focus of CBT and MI can vary, there are overlaps where either strategy can be applied, or more preferably, both are used as appropriate to complement each other. For example, some clients may find it difficult to identify goals for the CBT therapy to focus upon, and although CBT can assist in these, an MI approach may address this at an earlier stage, such as before a client even considers there is a problem to be addressed. A smooth segue then into CBT may assist with these clients to identify goals, and thereafter to assist with cognitive distortions that trap us and prevent us from achieving goals and enjoying our lives.

This is not to imply that CBT is best directed at those wishing to optimise an otherwise tolerable standard of wellness. There are many serious conditions that research has found to benefit from a CBT intervention, including:

• Depression
• Bipolar disorder
• Addictions (drug and behavioural)
• Anxiety issues including Obsessive-Compulsive disorder, phobias
• Eating disorders
• Schizophrenia and Psychosis
• Behavioural conditions in youth/adolescence
• Family issues
• Personality disorders and traits
• Sexual conditions

and has been found to be effective with pain management, adjustment dysphoria, anger management, sleep problems, general health problems, and many others. CBT can be used in a one-to-one process, or can be provided in a group therapy setting (Heimberg), with the advantages of clients experiencing that others are addressing similar issues to theirs, and learning/testing in a group process.

What is CBT

CBT is perhaps best described as an umbrella description for a range of therapeutic interventions that involve cognitions or thoughts, and it is these thoughts that influence how we feel and behave, rather than the event determining how we feel. There are various emphases by the different CBT umbrella approaches, with Cognitive Therapy (CT: Beck) focussing upon thinking that underlies the behaviour. Others are:

Community Reinforcement Approach (CRA)
Other approaches under the CBT umbrella include Community Reinforcement Approach (CRA: Azrin and Hunt; Meyers & Smith) which focus upon consequences, and less so, triggers, and the development of skills and coping behaviours often with voucher reinforcement. As with other interventions, therapists are empathetic, directive, and active in assisting the person to achieve their goals, even outside of the treatment sessions. The environment is structured to reinforce the client to achieve their goals.

Dialectical Behaviour Therapy (DBT)
Another intervention approach under the CBT umbrella is Dialectical Behaviour Therapy (DBT: Linehan) was originally developed specifically for Borderline Personality Disorder, to address its emotional dysregulation, but is expanding in its application (eg addressing suicidal ideation). Here the focus may be on the emotional mind and tolerating and accepting, rather than changing, the event/perception to minimise this effect. Therapy involves training that included ‘mindfulness’, interpersonal effectiveness, including assertiveness, ability to tolerate distress, and emotional regulation.

Acceptance & Commitment Therapy (ACT)
Other approaches include Acceptance and Commitment Therapy (ACT) that also uses mindfulness, which teaches clients to ‘just notice’ their stressful reactions, and accept, rather than avoid them, so as to distance themselves from the effect. The acronym ACT also refers to an alternative to the distressing reaction, namely Accept your reactions and be present, Choose a valued direction, and Take action.

Core Principles of Cognitive Behavioural Therapy
Core CBT focuses not only upon the thoughts, but also as might be expected from the description, the behaviour, and will also address ways to desensitise (in the case of phobias), reduce or end control by harmful behaviour (addictions), or assist to develop alternative behaviours. The behaviour modification will have aspects of Behaviour Therapy, but whereas this is viewed to have developed through conditioning and reinforcement (Learning Theory), CBT views that the additional and predominant effect is caused by thoughts or cognitions. These cognitions influence how we judge ourselves, the world, how our expectations affect our interpretations, and these influence our planning, our strategies, and the way we solve (or don’t solve) problems.

How do these faulty cognitions arise?

Cognitive therapists believe that ‘maladaptive’ cognitions arise from dysfunctional family upbringing, trauma in life, poor or non-development of coping skills, faulty social adaptation, and many other experiences in life that can result in depression, anxiety, addiction and other harmful conditions. Some (eg Beck) suggest that faulty thinking patterns can become relatively fixed from childhood, and operate automatically without the addition of conscious consideration. Although negative events do occur, for many this can be perceived as far more likely to arise, with costly and lasting consequences to their wellness. CBT posits that depression is often associated with irrational thoughts and biased, negative thinking.

CBT Therapy

Although focus and interventions will vary amongst the different CBT umbrella approaches, the core CBT therapy is very structured compared to many alternative approaches. Its two main components are functional analysis and skills training.

Functional analysis
The purpose is to identify cognitions or thoughts, emotions or feelings, and what was happening in their environment before the behaviour, or goal they wish to change; the consequences of the thoughts, and to identify risky situations for them to raise awareness and identify coping deficits.

Skills Training
The learning of coping skills to address the problem includes changing of past learning or habitual reactions, and to develop the ability to apply these skills in future situations. Underlying these two aims are addressing irrational or maladaptive perceptions, beliefs and assumptions of the client that may have resulted in the distressing condition, maintained that condition, and which may cause risk to recovery if change is made.

Approaches in CBT therapy
Using a Socratic approach, goals are developed, with homework between sessions. This may include keeping a diary of events and outcomes, feelings and objective analysis when distressing incidents occur, and development of coping options alternative to past dysfunctional resulting behaviours. As with Motivational Interviewing, the client identifies their goals, with a collaborative approach, rather than the therapist being in control. Testing through experiments is a common approach to raise insight and motivate development of skills that can be generalised to other future occasions. Practice and self-reinforcement enables the strategies to be integrated into the client’s usual behaviour, to replace the dysfunctional, often automatic behaviour.

Aims of CBT
Aims of the therapy are to change the distressing condition and achieve the other client-elected goals through development of coping skills, adjusting distorted thinking processes, and developing an understanding that their distressing emotions and behaviours are caused by their distorted thoughts and beliefs. Skills are taught to enable the client to dispute future events where appropriate, so as not to readily categorise them in ways that cause distress. Other skills, such as relaxation techniques, craving reduction and other self control/coping skills, assertiveness and other social skills, accuracy testing techniques, and others, will assist to address future stress-inducing events.

Summary

CBT is a well-proven, effective therapy, which has been found to be effective with a wide range of conditions and mental health disorders. It aligns with many other approaches, such as Motivational Interviewing and pharmacological treatment, and can be provided contemporaneously for clients. It has been shown to persist in its effectiveness, and is relatively brief to deliver. Its structured, but focussed approach to immediate issues, allows setting-specific tools to be provided that clients can relate to, and from which successful change can be demonstrated. Even more importantly, clients are able to attribute these changes to their own ability, and can experience prompt success that can facilitate the transfer of these skills. For health professionals, CBT provides a well-described approach that can be delivered over a short period of time, with the client continuing with the process between sessions, through insight-developing ‘homework’. CBT provides a solution for settings that require proven therapeutic interventions for health and health-related conditions in a time-limited manner, that can integrate with and deliver alongside pharmacological treatments, a common requirement when coexisting conditions are often the norm.