Thursday, December 29, 2011

Cognitive Behavioural Therapy

Cognitive Behavioural Therapy, CBT, is not new.  It was developed by Aaron Beck. I did 6 months of formal weekly training in this psychotherapy approach in my psychiatry residency in the mid 1980's.  At that time it was not a standard  part of the psychiatry residency. Psychoanalytic psychotherapy was the dominant form of therapy in my training program. CBT training was an 'elective' then whereas today it's fairly mainstream.
The principal behind CBT is that 'mood disorders' and other psychiatric dysfunctional states are a product of 'cognitive' internal process.  Simplified it says 'we feel what we think and behave what we feel.'  Therefore if you change your 'thinking' then feeling and behaviour will change accordingly.  Though the actual techniques that Beck developped were fairly original the idea of the effect of thinking on mood and behaviour was in fact ancient. It's part of the standard teaching of Christianity and Buddhist so heralds back thousands of years.  Beck himself acknowledged the origins of his work in the Stoic philosophers of the ancient world. In psychology 'positive thinking' therapy had turn of the century application in the early hypnotists proponents.  Mesner's  'Everyday in everyway I'm getting better and better" self affirmation may as well have been early CBT.
Beck's real genius was in the development of a particular strategy of positive thinking and teaching of this that could be replicated and reproduced to allow for scientific study of the basic premise. His methodology was such that with CBT alone there was an approximate 75% cure in the treatment of depression in a roughly a few months.. Without treatment depressions commonly lasted a year.  CBT was equal then to the response rates of patients treated with antidepressant medications. When the two forms of treatment were combined the response was enhanced even more.
In contrast to psychoanalytic psychotherapy which on a weekly basis similiarly administered resulted in relatively equivalent response rates, practitioners in CBT could be trained in shorter periods of time with great effectiveness.  My own training in psychoanalytic psychotherapy as a psychiatrist took place over 4 years and was quite intensive whereas I learned CBT in a matter of months.  Further CBT could be given to groups whereas psychoanalytic therapy was much more labour intensive and effective one on one.  Even better CBT could be self administered. Burns, a student of Aaron Beck, wrote the best seller 'Feeling Good' which today still stands as a terrific text for patients to be given suffering from mood disorders.
Being relatively cheap and easy to learn, it has also leant itself to being used as part of research, it's value shown to be beneficial far beyond just 'depression' and having benefit in anxiety disorders, thought disorders, and addictive processes.
In contrast to psychoanalytic therapy that worked to 'weed' out misinformation acquired in childhood, CBT focussed on the 'present' and didn't really consider it that important how a person had become 'misinformed' about how to think effectively.
For example 'catastrophizing', is seen as a 'cognitive distortion' in CBT.  It is recognised that people who tend to catastrophise in crisis are being 'irrational' and less 'effective'.  Individually, with a therapist or in a group one learns to 'identify' this trait, see it , in fact, as an 'error' and bypass it or work around it. The techniques that Dr. Beck developped for this included 'talking back' to the 'misinformation'.  As an example, "I don't get paid today because the mail doesn't arrive, I think, I'm not going to be able to pay the rent and am going to be homeless." Instead I should think, 'it's not the end of the world', I will contact the people who expect me to pay them that day and advise them that the mail has been delayed and I will pay them tomorrow. " This is 'normal reality' unless one is dealing with the mafia or government beaurocrats. Government beaurocrats actually respond humanly if you give them the same information in triplicate with a witness of a lawyer or doctor or prime minister as notary.   The world doesn't need to end.
Interestingly these 'irrational tendencies' were common and formed the basis of the development of the 'fallacies' in the study of 'logic'.  Beck's contribution was to simplify these 'fallacies'  for the lay person, counselloers,r psychologists and others by putting a memorable spin on them.  An example from Dr. Burn's list of Cognitive Distoritions in Feeling Good was 'disqualifying the positive".  In this situation the person says it doesn't matter if I have the money in the bank to cover the rent, I didn't get the cheque in the mail so I'm going to be homeless.  The nature of the focus here is to 'disqualify' the assets one has.
My mother used to say 'count your blessings' because frankly depressed and angry people commonly focus on the negatives and as long as they do commonly create a 'self fulfilling' prophecy. "CBT has been used in sports  training athletes not to 'psych themselves out' but rather to 'psych themselves up'
Ironically, the business psychology world had been using many variations on CBT in their 'inspirational' talks and 'motivational' sales training.  If anything the academic world in this case was commonly playing catch up to the business world and refining what worked.  Scientific study has proven what often common sense already knew.
Maslow, developped the term 'self actualization' in his study of highly successful people.  He wasn't a CBT therapist but rather his approach was to study 'well people' and then suggest that the very strategies that made them well be applied to helping the sick.  Freud had originally in the early years of the study of mental illness only treated 'sick' people and learned their differences.  Today therapists have learned many 'effective' ways of thinking from those leaders in society and are taking these strategies into psychiatry. Not surprisingly Thessalonians of the New Testatment of the Bible had CBT recommendations telling people to 'think on positive things'.
In addiction work Hal Morley, now deceased, always encouraged an 'attitude of gratitude'. He said with an 'attitude of gratitude' one simply could not remain depressed and negative.
In CBT work the relationship with the 'client' or 'patient' is much more like a 'teacher' student relationship than the traditional psychoanalytic psychotherapy relationship where transference and counter transference, the 'process' and the 'relationship' itself were the focus of therapy. In CBT patients are given 'home work.'  They are encouraged to 'journal' and it's accepted that 'success' in therapy is no different than one would expect for  'success' in geometry'. The more one does, the better one gets at 'changing' one's negative thinking to 'positive thinking' and 'purposeful and effective' living.
I commonly ask patients with depression to avoid daily news since it's commonly negative and fear mongering. In this way I'm not acting at all like a traditional psychoanalytic psychotherapist but am being very directive and drawing from my experience as a family physician addressing allergies in children. In that world I'd remove those things that caused sneezing and today in the process of CBT  I help the patient remove daily news for instance from their daily repetoire  and not uncommonly see patient's moods improve immediately.  I also tell the depressed to stop listening Sylvia Plath. An analytically oriented session in constrast would encourage a patient to reflect on the meaning of their listening to, say Kurt Cobain, when they were insisting they wanted to live not die.  I might simply tell a person to listen to Bach or Sarah McLaughlan or Bare Naked Ladies.
Going over a particular stress we would look at what the person was thinking and how they could think more effectively. The questions asked are 'what could you have done differently?  What would you have liked to have said."  What were you thinking?. What would be a better way of thinking given those events?."
Indeed in the Christian community there seems to be a bit of CBT going on when people ask 'What Would Jesus Think/Say/or Do?"
CBT has been called physiotherapy for the mind because it's done in much a way as a person with a physical injury goes to a physical therapist to learn how to walk or move an arm in recovery.  In CBT people are trained to think differently about situations, people and relationships.  Often pen and paper examples are used much as teachers do in the class room.  In group therapy, examples of difficulty are shared and other members are asked how one could think better about such an experience.
It's not 'rocket science'.  It's common sense, mostly. However in day to day reality people rarely are exposed to what others are thinking. They just see that a person is 'acting' poorly and rarely know how 'odd' and 'different' their thinking may be.
As CBT therapists can themselves 'think' their 'thinking' is 'superior' and come across unknowingly as terribly arrogant, I encourage everyone who has studied CBT to read Job in the Old Testament.  Job is a character who is blameless, thinks well indeed, and accurately but his friends faced with his difficulties do their own version of CBT without any benefit and far too much judgement and arrogance.
That said, CBT is a tremendous asset for anyone and worth the learning. There are superior therapies and ones which are better for specific conditions and individualized therapy is usually better than any of the 'off the rack' therapies.  I'm an 'eclectic psychotherapist' so I've been formally trained in several of the major modalities of psychotherapy so am least at risk of the criticism of 'give a boy a hammer and everything is a nail."  That said I'm very thankful for my training CBT a quarter century ago and the advances I've acquired in this modality over the intervening years. I doubt a day goes by I don't get to use some aspect of this therapy.
For anyone interested in CBT I strongly recommend Feeling Good, by Dr. Burns.  I still remains a classic and can often be bought cheaply at a second hand store. The first copy written circa 1980 was probably better than later editions anyway. It's bright yellow, like sunshine. Go Figure!

No comments: