What is cognitive-behavioral therapy?
Cognitive-behavioral therapy (CBT) is based upon two separate theoretical models, both cognitive and behavioral. Cognitive models are based upon the premise that cognitions, or thoughts, determine emotions and behavior. Automatic thoughts are one type of cognition that may be distorted by errors of thinking such as overgeneralization, catastrophic thinking, jumping to conclusions, or personalization. Errors in thinking tend to be more frequent and intense in depression as well as in other psychiatric disorders. Behavioral models are based upon theories of learning such as by modeling or by reinforcement to certain responses.
Cognitive-behavioral therapy uses techniques based upon the models described above. A greater emphasis on cognitive approaches or on behavioral approaches may be taken depending upon the disorder and the stage of treatment. Cognitive techniques include:
• Psycho education
• Modifying automatic thoughts
• Modifying schemas
Behavioral techniques include:
• Activity scheduling
• Breathing control
• Contingency contracting
• Desensitization/relaxation training
• Exposure and flooding
• Social skills training
• Thought stopping/distraction
Through many of these techniques, patients learn to manage their anxiety and reactions to stress appropriately. Exposure training is a technique that uses graded exposure to a high-anxiety situation by breaking the task into small steps that are focused on one by one.
CBT has been the best-studied form of psychotherapy, and it has been shown to effectively treat depression and thus can be a very effective treatment for acute cases of mild to moderate depression in bipolar disorder, when antidepressant exposure needs to be minimized.
Treatment typically lasts three to six months with ten to twenty weekly sessions. The patient is expected to be an active participant in trying out new strategies and will be expected to do homework.
Terms:
Automatic thoughts – thoughts that occur spontaneously whenever a specific, common event occurs in one’s life and which are often associated with depression.
Overgeneralization – the act of taking a specific event, usually psychologically traumatic, and applying one’s reactions to that event to an ever-increasing array of events that are not really in the same class but are perceived as such.
Catastrophic thinking – a type of automatic thought during which the individual quickly assumes the worst outcome for a given situation.
Schema – representations in the mind of the world that affect perception of and response to the environment.
Contingency – contracting use of reinforces, or rewards to modify behaviors.
Flooding – exposure to the maximal level of anxiety as quickly as possible.
Thought stopping – a technique used to suppress repetitive thoughts.
Graded exposure – a psychotherapeutic technique applied to rid a patient of specific phobias. A gradual exposure to the phobic situation is set about first through imagery techniques, then through limited exposure in time and intensity before full exposure occurs.
Are there any risks from engaging in psychotherapy?
Psychotherapy appears, on the surface, to be one of the most benign forms of medical therapies. There is (usually) no physical contact. No medications are prescribed. Only words are exchanged between people, nothing more. But never underestimate the force of words. There is a parable that may be recalled from childhood: “Sticks and stones may break my bones but names will never hurt me.” Such a parable was created to provide comfort from the emotional wounds received from being called names. Words carry power. Just as psychotherapy has the power to heal, it also has the power to harm. The various harms range from lack of progress to outright abuse. Most harm from psychotherapy comes from what are known as boundary violations between the therapist and the patient. The most obvious boundary violation stems from sexual or physical relationships that can develop between the therapist and patient. In many states this boundary violation is considered a criminal offense because the power differential between the patient and clinician is so great as to put the patient in a particularly vulnerable position.
Other boundary violations are not as obvious. Simple exchanges of personal information between the patient and therapist are often considered to be boundary violations and may or may not lead to more serious offenses on the part of the therapist. The potential dangers are that they may lead to friendly meetings that move beyond the office, and friendly meetings may turn more intimate. Many patients may experience their therapists as a friend; such feelings generated are known in therapy as transference. Transference is an artificial relationship that the patient projects onto the therapist. In insight-oriented or dynamic (Freudian) psychotherapy a transference relationship is intentionally created to allow the therapist to better understand a patient’s outside relationships. This in turn allows the therapist to help a patient develop insight or greater understanding into the unconscious motives behind his or her relationships so that healthy interactions can be learned.
Therapists also develop transference relationships with their patients, known as counter transference. If the therapist is unaware of his or her counter transference, then his or her behavior can reflect the therapist’s own outside relationships rather than the patient’s. If such relationships are problematic this in turn could be projected onto the patient. As a result a patient may be made to feel that he or she is experiencing problems that are really the problems of the therapist. Patients often idolize their therapist, which makes patients particularly vulnerable to the influence of their therapist’s words.
A notable example of the vulnerability patients can have in therapy occurred a few years back when some cases were made public of patients believing through their therapists’ suggestions that their parents sexually abused them. The process by which this occurred came about through the implantation of false memories on the part of their therapists. The therapists did not do this intentionally.
In their zeal to associate certain symptoms their patient’s presented with to a history of sexual abuse, they began to gradually convince their patients they had repressed memories of abuse. Once they had convinced their patients of past abuse, false memories could easily be constructed by asking them to imagine being abused or by implanting false memories through hypnosis. The term false memory syndrome was coined and several high profile legal cases occurred in which patients sued their therapists for psychological damages as a result of the patients taking action on their false memories.
How can you reduce such risks? You must rely primarily on referrals and word of mouth from friends as well as other professionals. Generally your primary care doctor has developed relationships with various therapists over the years and knows their work. Success in therapy isn’t so much dependent upon the academic degree of the therapist as is the therapist’s training and experience in treating patients. Secondarily, you need to maintain an open mind to make changes if uncomfortable with a particular therapist, no matter how skilled he or she may be. Chemistry between patient and therapist is needed, and no amount of training provides that for any particular patient. Success in therapy depends on how one feels about the therapy sessions as well as the motivation from the therapist to “do the work” outside of therapy in order to make the changes needed.
Leslie’s comments:
It is really important to do your homework when choosing an appropriate therapist. It’s easy to feel intimidated when speaking with a therapist for the first time but remember, in the simplest terms, you are a “consumer” of a “service” and therefore you need to find someone who will be a good fit for you as you do your work.
I made the mistake once of not doing enough homework. I saw a therapist for a few appointments and was made to feel like a dangerous “monster” because of my bipolar disorder; she was actually afraid of me. Needless to say, this experience did far more damage than good.
I am now in long term therapy with a licensed clinical social worker. We work very well together and she is extremely helpful as I face the challenges inherent in this disorder.
Term:
Dynamic – referring to a type of therapy that focuses on one’s interpersonal relationships, developmental experiences, and the transference relationship with his or her therapist. Also known as insight-oriented.
