Mention the word psychotherapy and many people immediately get a mental picture of a bearded and bespectacled physician, smoking a pipe. a la Sigmund Freud, intently listening,while taking notes, to a distraught patient who is stretched out on a leather chaise-lounge. Or they picture a character like Woody Allen, obsessing about never-ending sessions with his high-priced Manhattan shrink, which don’t yield any results. Maybe you think of Bob Newhart’s character on The Newhart Show, where he counseled a parade of loveable, kooky characters whose problems were comedic in nature and who never could get better, because that would signal the end of the show. We find these examples believable because, even though they are a bit far-fetched, they have a certain amount of familiarity to them.
Like a repairman has many different tools in his toolbox, Cognitive behavioral therapy, or CBT, is one of the tools I use to treat patients. CBT is the term used to describe one form of modern psychotherapy that is widely used to treat any number of emotional or mental problems, such as substance abuse, dependence and addiction; personality, eating or anxiety disorders and different psychoses.
CBT differs from other forms of psychotherapy in that it looks at conscious thinking (cognition) and behaviors (actions) that are not helpful and can cause problems for patients. It seeks to solve problems by changing thought processes and behaviors that are detrimental. It also acknowledges that all thoughts are not controllable or conscious. Pure psychoanalysis, for example, looks for the unconscious meanings behind troublesome thinking and behaviors that may have been formed early in life or through some traumatic event. Modern CBT acknowledges that both theories can be helpful when treating patients and looks to help patients address issues by using specific strategies to change thinking and behavior.
They are many types of CBT, some of which may be familiar to you, such as: exposure or aversion therapy, relaxation therapy, acceptance and commitment therapy, and mindfulness, to name a few. These therapies attempt to address cognitive distortions, such as catastrophizing, minimizing or denying positives, magnifying negatives, all-or-nothing thinking, etc., and to replace these with adaptive thinking skills and behaviors.
An example of a typical conversation with a patient who has cognitive distortion:
Patient – “I am so stupid, I will never graduate college. In fact, I shouldn’t even apply.
Physician – “Why do you say that? What makes you think that you are stupid? And that you will fail to get into college?’
Patient – “Everyone says so. They laugh at me in school when I answer incorrectly.”
Physician – Everyone? Your teacher laughs at you? Your best friend?
Patient – “Well, no, not them. But others make fun of me!”
Physician – “Be specific…who laughs at you in class?”
Patient – “Well, it happened once, I can’t remember who it was, but it was so terrible, I cried for the rest of the day.”
Physician – “So, one time, a person whose name you can’t remember, made you feel bad about a mistake in class. And that was enough to make you feel so bad, that you are not going to apply for college? You are going to let one person’s opinion impact your whole future? Would you recommend not applying to college to a friend who felt the same way you do?”
Patient – “You don’t know how I feel inside, so it is not for you to say. I would never tell my friends not to apply to college. None of my friends are as stupid as I am.”
Physician – “What kind of grades do you make?”
Patient – “I am in the honor society, mostly ‘A’s and some ‘B’s”.
Physician – “So, there is certainly academic evidence that you are not stupid, but very intelligent. I see that you care more about your friend’s feelings than you do your own, because you would not advise them to throw away the chance to go to college. And just because one jerk laughed at you, doesn’t make you stupid. ”
Patient – “Well, I feel that way”.
We can use the example above to illustrate the process steps used for treating patients with CBT.
Step 1: Identify critical behaviors (magnified, negative, distorted thinking)
Step 2: Determine whether critical behaviors are excesses or deficits (deficits of affirmation and positive self-talk, excess negative thoughts and self-abasement)
Step 3: Evaluate critical behaviors for frequency, duration, or intensity (obtain a baseline) Patient thinks about it every day in school, more often before a test)
Step 4: If excess, attempt to decrease frequency, duration, or intensity of behaviors; if deficits, attempt to increase behaviors. (Actions: write down every time you have a negative thought about your intellect, note day and time; repeat “I am smart and can succeed” instead. Pin copy of your report card to your mirror so that you can see evidence of your intellect. Apply to colleges of your choice.)
Although this is an extreme over-simplification, you get the picture. We seek to replace irrational, self-destructive thoughts and behaviors with those that are positive, rational, and action-oriented. Like most worthwhile pursuits, this takes practice and time on the part of the patient. You don’t change years of negative thoughts and behaviors in one day or one week. However, for those patients who approach CBT seriously, they can successfully change bad patterns and learn new ways of dealing with the stresses of life. In doing so, they become happier, healthier and live more fully.