A Guide to CBT Counselling
Cognitive Behavioural Therapy (CBT) is not about correcting faulty thinking, as is often simplistically suggested in the press; instead it is about helping people to understand how they have become trapped by their attention, reasoning and current coping strategies and how to find ways out of these traps. The focus is on helping people to find helpful ways of thinking and behaving. Thinking one will die if one falls whilst trying to escape from the top floor of a burning house might be ‘true’, but it is not a helpful focus. CBT achieves this by outlining how we respond to the world in a way that gives us a strategy to modify our experiences when these are causing us distress. First it divides our experience in to three components; THOUGHTS, FEELINGS AND BEHAVIOURS, then it explores the interactions between them. Initially these distinctions may seem obvious. However, they are not ones that we use on a day-to-day basis as generally we respond to the world in a reasonably automatic way. So breaking our experience down in this way takes some practice.
Thoughts are the things that go on in our minds, the words and statements. They are what someone would hear if they were sitting in our head, or what would appear in the thought bubble of a cartoon. They are heard in the first person, present tense e.g. “I really don’t want to go to work today”.
Feelings are described by the single words that we use to identify our emotions e.g. angry, sad, happy, and anxious.
The distinction between thoughts and feelings is not always easy to grasp and can take some practice. This is probably because the intensity of feelings is sometimes overwhelming, making it difficult to separate these different aspects of our experience. However the distinction between thoughts and feelings is an important one to make, one that is fundamental to CBT, as it is not possible to modify the components of our experience or influence the way they interact, if we can’t tell the difference between them.
Sometimes when feelings are either very negative or very strong we develop ways of blocking them out (e.g. keeping very busy, drinking alcohol, bingeing on food), this can make the task of identification and distinction harder still.
Behaviours are our observable actions, the things that we do, and so more often than not, the easiest of the three components to identify.
CBT suggests that when something happens, an event, we make an interpretation of that event and a thought occurs. That event can be either internal or external e.g. a memory or the actions of another person.
Depending on the nature of that thought, we will then experience a congruent feeling. A positive thought will led to a feeling of happiness, an anxious thought to panic. This feeling will then trigger further congruent thoughts. So for example when we are feeling low, we will find it much easier to access similarly negative thoughts, when we are feeling happy, similarly positive thoughts are more accessible to us. A feedback loop is created leading to the perpetuation of mood states. We typically see this in those stuck in depressive episodes or experiencing chronically high levels of anxiety.
The nature of the feeling will then influence what we do, i.e. it will trigger a behaviour. Anxiety will motivate us to take action, for example before an exam, it may motivate us to revise. The behaviour will then trigger additional feelings, so feeling depressed may lead a person to withdraw (behaviour), resulting in their mood (feelings) dropping further. A second feedback loop is created. Our behaviour also influences our thinking, creating a third feedback loop. For example trying something new (behaviour) will reinforce thoughts about our capacity to takes risks and cope well with them.
Here are some examples:
These are very simple examples but they illustrate the point that the way we think can significantly influence the way we feel and then how we behave. However, this is often not how it feels. Sometimes it can feel as if a direct link exists between the event and the feeling or the event and the behaviour, so that when something happens and we just feel something, or an event occurs and we just do something. A good example of this is the experience of driving to a place that you have been too many times and realizing when you arrive that you cannot really recall getting there.
We know that these direct links cannot exist because if they did no one would leave the house and everyone would vomit after eating donuts. So why does it feel like this?
Our minds are full of thoughts; there is a constant stream of them. If we paid attention to all of them we would not get anything done. So what it seems happens, is that those thoughts that occur most often slip just below the level of our conscious awareness. The circuit of thoughts, feelings and behaviours becomes like a well run track and a groove is created enabling these regularly occurring thoughts to drop down into it just out of our conscious awareness. This has the advantage of allowing us to attend to new thoughts, the old ones continuing to occur automatically triggering congruent feelings and behaviours without the need for our conscious interference. This system works well as long as these ‘automatic’ thoughts are not triggering distressing feelings and unhelpful behaviours.
CBT Counselling in Action
CBT Counselling can be useful when our ‘automatic’ thoughts become negative and begin to trigger negative feelings and behaviours. This is not to suggest that CBT Counselling simply encourages positive thinking as a way of resolving real and distressing problems. However it does take advantage of the fact that our thoughts heavily influence our feelings and behaviours. Usually when we are overwhelmed by our problems our thoughts become distorted or skewed in some way, so that important information that would help us feel and behave in a more adaptive way is filtered out. CBT Counselling aims to identify these thoughts, evaluate their accuracy and then if necessary restructure them so that they offer a more balanced reflection of reality. Such a change in our thoughts will lead to changes in our feelings and behaviours.
CBT Counselling also takes advantages of the other interactions that exist between the components of our experience. It will teach you strategies to regulate and improve your mood whilst also helping you to tolerate negative feelings more easily. This will impact both on your behaviour and your thoughts. In addition CBT Counselling will enable you to make specific changes in your behaviour which will again have a knock on effect on both your thoughts and feelings.
CBT Counselling was originally developed as a treatment for depression but has subsequently been adapted for a range of problems and to date provides one of the most effective solutions for emotional distress.
What to expect from your treatment
When people begin a CBT programme they understandably hope that things will gradually improve. However change is challenging particularly if you are working to change behaviours that help you to cope in the short term. Added to this is the fact that in order to resolve a problem you must focus on it, an increased awareness of your problem will make it feel more significant.
Instead what happens when you begin to resolve an problem is that you may feel worse and this initial rise in discomfort and distress can make you doubt the process of change. However, as you begin to understand more about your problem, why it developed, why you are now so stuck and what you can do to change things, you will start to feel that things are improving. You will still have bad days but the bad days will become less frequent and when they do occur, they will be less intense. The process of change is so challenging because in the short term you have to tolerate many of the disadvantages of change with few of the advantages. It is only it you can continue with change that you reach the long term benefits that come with resolving of your problem.
One way to think about the process of recovery is to think of a trek along the coastline of South America. You had initially hoped to travel from coast to coast by car, taking a smooth road across the centre of the country, but you are told at the last minute that there is no such road and instead you must walk, setting off in what intuitively seems like the wrong direction (the equivalent of starting in southern Chile and then dropping down to the southern most tip of South America). As you round the headland you begin to feel as if you are starting to go the right way (beginning to trek up the coast of Argentina) but from time to time the coastal path will take you inland away from the coast line and you will feel as if you are diverging from the correct path. However, if you keep moving, following the signs pointed out by your guides you will eventually reach your desired destination.
The trek along the coastline of South America can also be used to think about the core goal of CBT counselling; becoming your own therapist. During the first phase of your trek your Guide (your Psychologist) will teach you the various skills you need for your journey, taking the lead through the sometimes challenging terrain. However as you become a more accomplished trekker/therapist you will begin to feel more confident about taking the lead. Although when you have finished your CBT treatment you will not have completely resolved your problem, you will feel in a much stronger position to continue your journey along the coastline to recovery independently.
How is CBT different from other types of counselling?
1. The Evidence
The most important distinguishing feature of CBT is the evidence that supports it. The National Institute of Clinical Excellence (NICE – the government body responsible for providing national health care guidance on the promotion of good health and the prevention and treatment of ill health) recommends it as the treatment of choice for a range of mental health problems including Anxiety, Depression, Obsessive Compulsive Disorder, Post Traumatic Stress Disorder and Eating Disorders. CBT’s effect has been proven time and time again in randomised control trials (the most rigorous way of determining whether a cause-effect relation exists between treatment and outcome) and a wealth of published research studies exist supporting its efficacy (e.g. Cochrane Review – a group of over 10,000 volunteers in more than 90 countries who review the effects of health care interventions tested in biomedical randomized controlled trials). CBT is the only psychotherapeutic approach with such a robust evidence base across a range of mental health problems.
2. A Short Term Treatment
CBT is frequently presented as a ‘short term treatment’ and although in comparison to other types of ‘talking therapy’ it is certainly time limited, it is important to dispel the myth that it offers a quick fix. CBT is used to treat problems that are interfering with a person ability to function in one or more areas of their life. These problems are real, significant and often long standing and so it stands to reason that to resolve such problems a certain amount of time and energy is going to be needed. A problem that is quick and easy to resolve would not need a course of therapy from a highly trained professional. The number of CBT sessions that a person needs depends on the severity and chronicity of symptoms but an average minimum is between 15-20 sessions. Many other psychotherapeutic programs (e.g. psychodynamic psychotherapy) can continue for years.
The features that enable CBT to be a ‘short term’ treatment are also important in distinguishing it from other psychotherapeutic approaches.
2.1 Problem Focused And Goal Oriented
CBT focuses on resolving specific problems. During the initial assessment (first 1-3 sessions) the therapist will develop a Problem Formulation which will enable both therapist and patient to understand how the problem has developed and why (up until this point) it has not been resolved. This formulation is then used to guide treatment towards specific goals (identified collaboratively by therapist and patient) that when reached will signify the resolution of the presenting problem. Throughout treatment the initial problem formulation will be reviewed and updated to included additional information that may come to light and treatment is reviewed at regular intervals to ensure that progress towards the end goals is being made. This shared understanding of the problem and a clearly defined end goal ensures that treatment is as effective and efficient as possible.
2.2 Becoming Your Own Therapist
The ultimate goal of CBT is for the patient to become their own therapist. In some types of counselling the therapist is set up as the ‘expert’ who imparts knowledge of a seemingly inaccessible nature which can leave the patient feeling dependent upon the therapist and can undermine their confidence in their own capacity to resolve problems. In CBT therapist and patient work together so that the patients can learn a set of skills (practical and psychological) which can be integrated with their existing a knowledge so that they are eventually able to independently resolve not only current problems but tackle future ones without the need for additional counselling. This means that usually only one course of treatment is necessary thus reducing the likelihood that ‘longer term’ input will be needed. The following analogy illustrates this goal:
“An oyster creates a pearl out of a grain of sand. The grain of sand is an irritant to the oyster. In response to the discomfort, the oyster creates a smooth protective coating that encases the sand and provides relief. The result is a beautiful pearl.
For an Oyster, an irritant becomes the seed for something new. Similarly (CBT Counselling) can help you develop something valuable from your current discomfort. The skills taught… will help you feel better and will continue to have value in your life long after your original problems are gone”.
– Greenberger & Padesky 1995
2.3 A ‘Here and Now’ Therapy
CBT is often described as a ‘Here and Now’ therapy however it is important to be clear about what this means as this term is frequently misunderstood and used to imply that CBT is not suitable for resolving complex problems. In the initial phase of CBT the focus is on alleviating the symptoms that the patients is currently experiencing (e.g. panic attacks, low mood) by addressing the factors that are maintaining them. This is done not only to bring relief to the patient but where appropriate (i.e. for severe/long standing problems) to release some capacity for the patient to focus on exploring and resolving the factors that have contributed to the problem developing in the first place. In this second phase of treatment (often thought of as the domain of longer term psychotherapeutic approaches) an extended (but less popularised) version of CBT is utilised (Schema Focused CBT) which has been specifically developed to ensure that ‘here and now’ improvements are consolidated and to protect against future relapse. Although this second phase extends the length of treatment, as it continues to utilise the feature outlined above it represents a significantly more time efficient way of resolving long standing problems than other types of counselling traditionally used to tackle such issues.
Supporting Evidence For CBT Counselling
CBT Counselling is an evidence based treatment. This means it uses evidence from research and clinical studies to develop effective treatment programmes. These are then tailored to individuals and the problems that they are seeking help to resolve.
The National Institute for Clinical Excellence is the organisation responsible for providing national health care guidance on the promotion of good health and the prevention and treatment of ill health. Recently they have reviewed the available treatments for a range of mental health problems and have found CBT Counselling to be the most effective intervention. Below you can download PDF versions of the guidelines.