The Cognitive Behavioral Miracle – Controlling your Emotions




Most people who have never experienced a cognitive behavioral therapy (CBT) session, or at least read about it, tend to share the notion that what psychologists do is pretty much listen to your problems, sometimes offer advice and different points of view, and make you think about your feelings, actions, and emotions. In this popular view of therapy, the patient (or client) is a rather passive subject, and the therapist is the one doing the work. Personally, I don’t think there has been a more profound revolution in the study of human psychology as the cognitive behavioral revolution.

I first became fascinated with CBT while translating and editing some course materials for the director of the CBT Institute in Ireland, Sylvia Buet. I then discovered that when one mentions behavioral, most people would think of Pavlov-style basic stimuli-response training; while CBT was in reality much more complex. Buet in particular teaches her CBT students to ask clients to sign a contract at the beginning of therapy, which binds them to work to solve their own problems. Esteban Mello, the director of the CBT Institute in Uruguay, consistently uses half of each session to explain the tasks the consulting individual will be expected to perform before their next appointment. In this scenarios, the stereotypical idea of a person who goes to therapy to “take a load off” every week becomes completely obsolete.

In a nutshell

The principles of CBT are based on a very simple idea: we feel according to what we think, in other words, our thoughts and cognitive constructions are at the root of our emotions and behavior patterns. CBT is based on three fundamental propositions:

  1. Cognitive activity affects behavior;
  2. Cognitive activity may be monitored and altered; and
  3. Desired behavior change may be effected through cognitive change.

The original theoretical framework of CBT stems from two main sources, Ellis’ rational emotive behavioral therapy, known as REBT and Beck’s cognitive therapy. Drawing from a concept already present in ancient Greek philosophy, Ellis established the A-B-C-model, where A stands for adversity/activating event, B stands for beliefs and C for consequences. The idea is that while people think that they get upset (consequence) because of an adversity (A) (i.e. something “bad” that happened to them), in reality they get upset because of their beliefs (B) about what happened, and everything negative they associate with the event in their minds, and not because of the adversity itself.

On the other hand, Beck developed cognitive therapy (CT), which focused on the identification of dysfunctional thinking, behavior, and emotional responses, emphasizing on patient-therapist collaboration and a belief-testing dynamic.

Today, CBT encompasses a variety of therapies that share a basic core, one of the most salient characteristics all of these therapies have in common is their standardised protocol of testing and measuring results before any treatment is approved. This means that specific randomized controlled trials must yield significantly positive results, in order for treatments to be adopted. Only when consistently positive results are observed when comparing to treatments based on other therapeutic approaches, can the prospective CBT treatments become an acceptable option.

Problem classification

There are different classes of CBT that are used to deal with different kinds of problems. Cognitive behavioral therapists classify problems according to the degree of influence the individual has on them and their outcomes. While coping skills are the main focus when treating problems which are caused and governed by external factors, cognitive restructuring is the method of choice when dealing with problems that originate from the individual.

One of the first things Mello teaches his patients is to class problems in three different categories:

  1. Problems upon which the individual has no control whatsoever;
  2. Problems that depend partially on the individual and partially on external factors; and
  3. Problems that depend solely on the individual.

For example, a death in the family would be a problem of the first kind. However, if we feel that having a good time after our loved one’s passing implies that we have no respect for them, or that we didn´t love them enough; we may be developing a problem of the second kind, where we have a certain control of the situation, though there are some factors over which we can have no influence. In these cases, CBT will focus on altering these beliefs, so that the person can continue to have a normal, healthy life, without feeling guilty about it.

If we asked the person in this last example, what they are upset about, they would most likely answer “because so-and-so died.” They would thus be focusing on Ellis’ A or adversity, when in reality, what is making them upset is B (i.e. their own beliefs about their loved one´s death´s meaning).

Proven results

According to the Beck Institute, over 500 scientific studies have proven that CBT has had significantly better results than any other therapeutic approach for a growing number of disorders and problems. These include obsessive compulsive disorder, general anxiety disorder, post-traumatic stress disorder, bulimia, drug and alcohol abuse, social phobias and dissociative disorders, among many others.

Conclusions

CBT is a fundamentally empowering approach, in that it has successfully identified certain ways of thinking that can make the difference between sanity and insanity, between happiness and unhappiness, and it has developed a variety of techniques to teach patients to substitute these dysfunctional patterns of thinking, which are often at the root of their problems.

As research progresses and the theoretical framework expands and evolves, and judging from its past evolution, it is possible to predict that CBT will continue to develop more and more effective techniques and strategies to help patients dealing with all kinds of psychological and psychiatric problems.

References

Dobson KS. Handbook of cognitive-behavioral therapies (3rd ed.). New York, 2009: Guilford Press.

Ellis, A. (1980). Rational-emotive therapy and cognitive behavior therapy: Similarities and differences Cognitive Therapy and Research, 4 (4), 325-340 DOI: 10.1007/BF01178210

Warren R, & Thomas JC (2001). Cognitive-behavior therapy of obsessive-compulsive disorder in private practice: an effectiveness study. Journal of anxiety disorders, 15 (4), 277-85 PMID: 11474814

Quinn TP. The effect of cognitive behavioral therapy (CBT) on driving while intoxicated offenders. PhD Dissertation, State University of New York at Albany, 2011.

Image via Kovalchuk Oleksandr / Shutterstock.

  • Richard Kensinger, MSW

    No ? in my clinical experience that CBT is quite efficacious in a number of clinical situations. I do believe that there is an intimate interactive between thinking & feeling. Across cultures we do find universally expressed emotions. Cultural display rules potently govern how we show emotions in public.

    Many transtheoretical therapies show common healing pathways. So, perhaps at any entry point by altering thoughts or emotions, or behaviors, we can trigger meaningful therapeutic change in 75 ~ 80% of our clients.

    Rich

    • Thanks for the insightful comment.
      I fully agree.

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  • Miek P

    Maybe, it’s interesting to read the following link about the myth that CBT is proven to be better than other forms of psychotherapy (for the diseases you mention, like anxiety):
    http://www.scottdmiller.com/?q=node%2F160&utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+scott_dm+%28Scott+D.+Miller%27s+blog%29

    So one can really question the external validity of the studies of the CBT-scientists, like the Beck institute (because the reliability of the studies about ‘being better than other psychotherapies’ is questionable: an important positive publication bias, allegiance of the author to his own form of therapy (CBT most of the time), giving a flaw version of ‘the other’ psychotherapy, frequently by a CBT-therapist,…).

    conclusion: It doesn’t seem that CBT is superior above another form of psychotherapy (I suppose ‘bonafide’), even if the government forces patients, who search for help, to CBT. That’s the conclusion after ‘a real life test’ for millions of people within a period of 10 years.

    Such an impressive reality means a lot more to me than maybe 1000 studies of CBT-researchers. It’s not because CBT has 10.000 studies in which they show that they are effective for a disease (read: some people can be helped by CBT) and another form of psychotherapy has 1000 studies that it’s effective for that same disease, that CBT is automatically superior than that other form of psychotherapy because it has more studies. That is a biased conclusion (= the myth of CBT)!

    So, I’m not saying that CBT is not effective for …% of the people, but I really question the superiority of CBT for problems like anxiety (and a lot of other psychiatric diseases as well) above another bonafide psychotherapy. So I wouldn’t know why CBT should be sees as a miracle… A bit of humility is never bad, I think.
    It’s quite an impressive argument for the Dodo Bird verdict too…

    And sorry if I didn’t spell everything correct, but English is not my mother tongue.

    • Thanks for your comment.
      Personally, I think CBT may not be for everyone. In fact, I think who the therapist is and what his personal methods are plays a key role as well,
      I recently recommended CBT for someone trying to get over a breakup, and was surprised to learn that the accredited CBT professional in question held sessions where very few CBT elements were at play.
      It is unquestionable that CBT has been proven to show good results after a shorter period of time. As for the likelihood of success, it may lie, as any other kind of therapeutic approach on the dynamic of the patient-therapist relationship and just how committed the patient is to solve their problems.

  • Richard Kensinger, MSW

    Across therapy approaches, here are 4 documented change factors: catharsis,the freedom to explore expanded options, enhanced mindfulness, & experimentation to think, feel & behave differently.

    In addition, 75 ~ 80% of clients show a + response to psychotherapy. Here are the relative contributing factors:
    Placebo 15%, Clinical strategies 15%, client strengths & resources 40%, & the therapeutic alliance 30%.

    Rich

    • Miek P

      You’re right… The study of Lambert…
      The most important factor is the relation between the therapist and the client. The method (CBT or another one) doesn’t count for so much (15% of the result). Especially when studies have also shown that a lot of the other forms of psychotherapy also have useful ‘techniques’. Like psychodynamic therapy, solution-focused therapy, MBCT, emotion focused therapy, mentalisation based therapy, ACT,… All these have proven to be as effective, sometimes more effective (!) than CBT, sometimes less, for some disease. All of them are evidence based for (some) diseases. And all of them hope/ try to gather some money to do studies to prove that their therapy works too, for other diseases. Remember that till now, in Sweden & already many years in GB the only sponsored therapy is CBT, so only CBT-researchers gets money from the gouvernment to do their studies. The other therapies who have shown now that they are evidence based too, don’t get money of the government for doing research. I find this a very unhealthy situation, also for the clients (like you can see in Sweden). The reason for that was/ is the blind believe in ‘CBT is the best’ and so we need nothing else. But… the results show that we need better therapies than CBT (like I will explain now, under this).

      I find it very irritant to read things like: ‘Depression can be solved by CBT in 15 sessions (or something like that)’. It gives people the false idea that CBT heals depression, in 15 sessions. But they forget to tell that +/- 50% of the people will have another episode of depression in the next few years! And after this one, another one… Nowadays, if you’re lucky, you begin to see that researchers call depression a chronic disease (for +/- 50% of the persons who had 1 episode). I also know that clients are not always so happy if they see that, even if they had CBT, they have another episode of depression, and another one. One reason more, for them, to think that it’s their fault that they are depressive again (because ‘CBT can heal depression in 15 sessions’, why can’t I heal then?)…

      The common factors are the most important factors, while a lot of people wrongly suppose that the technique is doing everything and that everyone can become a therapist if he learns to use the right techniques.

      By the way, the relativity of the idea that ‘CBT is more effective than other therapies’ is also shown, I think, in the fact that the third generation of behavioral therapy is a mix of CBT, of psychodynamic techniques and of experiential methods (like gestalt therapy, or emotion focused therapy (the chair dialogues)). And, I think, in the fact that most of the CBT-therapists I work with (not the researchers) don’t really believe in the statement that they deliver better work than non-CBT therapists.

    • Matt, LCSW

      This is a good point. My observation has been that when a client believes that my approach will work for them, or it makes sense to them, the therapeutic alliance is strengthened as well. So the two might be more intertwined. I’d like to think that to some extent there are interventions that work in a given situation and those that are less effective. Just my observation as a therapist.

  • Tools, tools, we all need tools and CBT is a useful tool in the hands of a competent therapist. Was it Maslow who said “If the only tool you have is a hammer, everything becomes a nail.” Or something like that. I do think Linehan’s work expands on CBT and gives the tool of mindfulness which is very useful. Talk therapy is useful for some but not for all, everyone needs a different tool.

    Pinned your article on my How We Grow and Change Pinterest board.

    http://pinterest.com/pin/147141112795985759/

    Thank you for sharing your knowledge.

    • Thanks, Katherine!

      I agree 100%.
      I personally thought CBT was nearly flawless, until I heard of bad CBT therapists.
      I still believe the tool is fantastic, but it is nothing without a good mechanic.

    • Matt, LCSW

      I started practicing as a pretty strict CBT therapist, but as I have slowly been introduced to the concept of mindfulness in many different ways, it has blessed me personally, and I think been a great addition to my therapeutic approach.

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  • Jaqueline Friedberg

    It is our point of reference in out conduct often changes how we see things. Sometimes this alteration is good and sometimes this change is bad but it is our point of view that controls how we feel.

Veronica Pamoukaghlian, MA

Veronica Pamoukaghlian, MA, holds a Masters in Creative Writing. She has directed two documentaries shot in psychiatric wards and a feature documentary about the 77-year old senior Decathlon champion of the world, Raul. Her last production is Monstruo, a short film about non-voluntary euthanasia. She is the CEO of Uruguayan film production company Nektar FIlms. You may visit her blog at The Wander Life
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