Cognitive-behavior therapy (CBT) represents a collection of therapies with a unifying philosophy, capable of treating problems ranging from eating disorders to insomnia. Cognitive-behavior theory posits that while we may not have much direct control over distressing emotions, we have partial influence over our thoughts and, in particular, our behavior. Modifying these processes may have downstream effects on how we feel.
CBT has its roots in the treatment of depression. At the time of its creation, the predominant theories of psychoanalysis suggested that depression stemmed from the “turning inward” of anger which patients could not otherwise consciously tolerate. Aaron Beck, widely considered to be the creator of modern CBT, did not perceive his depressed patients to be angry. Instead, he noticed that depressed individuals have characteristic styles of thinking (like black and white thinking) and relentless, self-critical thoughts. He sought to treat depression by identifying and modifying 'depressogenic' thoughts and behaviors.
Cognitive-behavior therapies focus on the “here-and-now” and on observable thoughts/behaviors. The hypothetical causes of the problem are deemphasized; factors keeping the problem going in the present are the focus. If whatever is maintaining a particular problem can be addressed, the problem will improve and may continue to do so even after therapy has concluded. In order to demolish a 'house of cards', one need not remove every card, but rather the pillars and foundational pieces. Thus, discovering the “cause” of a particular problem is viewed as largely irrelevant in CBT for treatment occur. What if there are multiple causes for a mental health issues, representing an array of biological, social, and psychological factors? Even if all of the “causes” could be identified in therapy, would this alone result in change? Or would one still have to work on changing?
Self-monitoring, a common CBT strategy, involves noticing and tracking thoughts, feelings, or behaviors which the therapy is attempting to modify. Tracking moods over time, keeping a food diary, and counting episodes of self-injury are all examples of self-monitoring. Self-monitoring increases mindful awareness of the problem at hand, generates a record against which the effectiveness of the treatment can be measured, and can also result in behavior change if the self-monitoring is conducted real-time. Individuals attempting to quit smoking who count the number of cigarettes they smoke as they smoke typically decrease their cigarette consumption by approximately 10%, even if they employ no other strategies for change.
Cognitive-behavior therapies generally employ four major tools for change: skills training, cognitive restructuring, exposure, and contingency management. Skills training is appropriate when a problems relates to a skill deficit. For example, some individuals may not have learned how to tolerate distress or regulate their emotions; therapy can teach such skills. Cognitive restructuring involves identifying, testing out, and challenging thoughts and beliefs which might impede healthy functioning. In cognitive restructuring, the role of the therapist is not to tell the patient that his or her beliefs are “irrational”, but rather to foster an attitude of empiricism on the part of the patient. Unhelpful or irrational thoughts and beliefs are viewed as hypotheses to be tested. For example, individuals with generalized anxiety disorder often have positive beliefs about worrying, such as, “Worrying prevents bad things from happening to me”. Such a belief could be put to the test by freely worrying one week and limiting worry the next, while tracking the number of negative events that actually occur. In exposure, patients 'act opposite' of unjustified emotions. Gradual exposure to avoided situations, places, people, etc. changes problematic emotions by promoting desensization and habituation to them. Someone who knows how to relax but avoids it due to feelings of guilt or fears of “being unproductive” could practice attempting to relax in spite of these feelings, eventually reducing their power. In contingency management, problems in the environment are addressed, to ensure that the environmental rewards and punishments support healthier behavior. Individuals in therapy can also learn how use positive reinforcement on themselves to become better at self-management. A patient is openly taught to use these change strategies by practicing in session and via homework assignments in order to nudge the patient toward functioning ‘as their own therapist', reducing the risk of relapse after therapy has come to an end.
CBT is intended to be efficient, shorter-term, and goal-oriented. Sessions tend to be directed by the therapist and the mutually agreed upon goals for treatment; both parties set a session agenda before diving into whatever might be on the patient's mind. CBT therapists encourage patients to form clear, behaviorally-defined goals for treatment. Goals such as “I want to stop self-injuring” or “I want to be happier” are not considered to be optimal goals. The former does not suggest what the patient will be doing instead of self-injuring. The latter does not define what happiness is, how the patient would know if he or she were happy, nor what thoughts and behaviors will become present/absent if the patient were to be happier. CBT sessions are structured. The CBT therapist and patient typically review homework, set a agenda for the remainder of the session, and then agree upon tasks for the patient to try in between sessions in order to hasten progress.
While different cognitive-behavior therapies share a common foundation, treatments for different disorders emphasize different techniques. CBT for depression emphasizes the restructuring of depressogenic thoughts/beliefs and scheduling positive activities. Treatments for anxiety disorders emphasize exposure over attempting to challenge anxious thoughts. CBT for eating disorders emphasizes establishing regular eating and a meal plan, restoring weight (if necessary), exposure to feared foods, reducing body/weight checking and avoidance behaviors, and modifying self-esteem so as to decrease the over-evaluation of weight, shape, and the control of eating.
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