Wednesday, June 19, 2013

Cognitive Behavioural Therapy - CBT

Cognitive Behavioural Therapy was developed first by Aaron Beck.  Feeling Good, by Dr. Burns is a book by Dr. Becks student that best summarizes some of the techniques developed by Dr. Beck. 

First, the principal of Cognitive Behavioural Therapy, CBT, was that 'what you think" is 'what you feel'.  Hence the program worked with the 'conscious mind' as opposed the psychoanalytic therapy that felt the emotional substrate was best accessed through 'unconscious' processes such as 'free association' and 'interpretation'. 

CBT was and is rather straight forward.  It's success followed it's simplicity and use by those trained in a limitted process.  It gave itself to reproducible formats and protocoled work books which could be used more easily in scientific research than previous therapies that often depended on the extent of training and experience of therapist.   Because it is essentially an "educational" model of 'relationship therapy' a counsellor could be taught how to do CBT, reducing costs of specialist services and it was commonly coupled with drug studies.  All manner of "work book' and 'take home' materials have been developped for accompany therapy.

I formally trained in Cognitive Behavioural Therapy as a psychiatry resident in 6 months weekly weekly psychotherapy supervision.  Because of the metaphor of computers and 're programming' the model of 'CBT' has had a currency that is as timely today as Freud's model was in it's scientific day.

Some standard examples of Cognitive Behavioural Therapy include the following:

1)  Identify the various 'negative self talk' that is used.
eg. "I'm no good" , "I'm a failure", "Everything is hopeless."  "Nobody cares for me"
(The list is endless)
2) These have been called "cognitive distortions'.  Often psychologists will take old ideas and repackage them with new labels.  The cognitive distorions of CBT to a large extent were first identified in philosophy and logic as "fallacious' thinking. There are various lists of common 'fallacies'.
3) In the examples given one would by oneself or with a counsellor reflect on the internal error in this self talk.  For instance , "I'm no good".  The word 'good' or 'bad' here is used as a 'generalization' and when one seriously breaks down the statement of what "I am" it's usually meant that I am 'no good at doing something' Ie 'pleasing my mother, pleasing my boyfriend, pleasing society, pleasing my boss".   
4) Each negative 'self talk' is explored rationally and then replaced by a more positive statement.  Eg.  "I'm no good" is replaced by "I am okay'.  Here the Transactional Analysis movement was a precurser in terms of Cognitive Behavioural Therapy and many of the ideas of Dr. Berne who developed this Cognitive Behavioural Therapeutic system, best described in the book "Games People Play', can be collapsed into standard CBT
5) Self talk is often done initially as a positive form of communication and one can write the short form of the outcome in columns.  So that whenever I say to myself "I'm no good" I don't again go through the whole process but instead say, "I'm okay" and possibly add to this "I breathe well, I've five fingers and toes, I'm a child of God, I macrame well, my hampster thinks I'm okay" whatever the list is to re inforce the positive counter thought to the negative recurrent cognitive distortion.
6) Other forms of CBT homework include writing out lists of all the good things I have done rather than focussing on all the negative.  To achieve this a criminal might say I was in jail 10 years but the therapist would say, 'you're 40 years old' so for 30 years you were not in jail.  If a matter like 'lying' behaviour is addressed, the person might list how many hours or days they didn't lie. 
7) Patient doing CBT are encouraged to read and record positive statements and positive reading material. It's not 'pollyanna' but rather optimistic. Depressed patients for whom CBT was first developped were so far out in left field that they didn't even have a glass to have it half filled so CBT is by nature 'optimistic' and 'positive thinking' in the conventional and traditional sense but realizing that the ideas might not be 'true' in a strictly rational sense but surely 'counter balance' the preponderance of negativity that people who use CBT first encounter.
8) The Behavioural aspect of CBT therapy looks at changing behaviour to change feelings. So if a person calls their wife names and she gets a restraining order, CBT would suggest that maybe this husband should not call his wife names if he wants to avoid a restraining order.
9) Another example of CBT is the writing of the events around trauma. Dr. Judith Wallenstein , the leading authority on PTSD at Harvard recommends that people who have experienced trauma write their "trauma story" as a kind of 'police report' then on the second line write the emotions that would be appropriate to the events.  During this process the person is to stop whenever they feel agitated rather than be 'retraumatised by the recall'.  This 'dissociation' recurrence is common in people who simply tell their trauma over and over again but never get on with life.  CBT encourages people to look at an event from 'multiple foci' rather than only seeing an 'event' from one perspective.
10) A typical CBT recommendation is to call a person when one is having negative thoughts rather than remaining alone with the negative thoughts.  There are Suicide Support Lines and Mental Health Support lines simply because "misery loves company' , a 'problem shared is a problem halved", the realization that one of the principle ways of breaking a negative chain of negative thinking is to talk to another person rather than 'nursing' the 'resentment' or 'bad mood' or 'negative thoughts'.
11) At one point for several years I had patients chart their moods with numbers 1-5 against other aspects of their daily life, eg sleep (hours), work (hours),  exercise (hours) , meals (number per day), positive meeting attendances (number per week or hours per week). In hospitals the nurses kept such graphs and we could see that patients moods, especially on geriatric wards, were commonly affected by lack of sleep or missing meals.  I also had as a family physician done several great detective hunts to find what was causing children patient to have allergic reactions or environmentally induced athmatic attacks. Given the CBT idea that changing the thoughts and behaviour would change the mood and ultimately improve thoughts and behaviour, this search for 'negative' triggers has often been quite fruitful.  People have found that certain 'friends' indeed were 'soul suckers' and didn't really want the patient to improve because they enjoyed their being down and as a 'sob sister'.  Often becoming emotionally well requires one to get away from emotionally draining people, not as a first resort, because more often than not we take our problems with us, but ultimately as a solution when others have failed.
I personally have to limit the amount of 'news' I watch because 'news' is marketted as 'depressing' and 'anxiety provoking. I once wondered why when my life was just fine I wasn't feeling a hundred percent and the answer was that I was allowing myself to be bombarded with all the problems of the world without any real way of my helping or changing matters.  One of the negatives of 'global community' is that much false information comes from a distance and we are commonly subjected to the insinuating blaming and begging that goes with 'enquiring minds need to know'.  So many of my patients have come in depressed simply because they are 'news aholics' and simply need to get away from the boob tube and computer screen.
12) Today in terms of Cognitive Behavioural Therapy I am as likely to recommend a person learn an 'affirmation' or positive prayer and use this as a 'thought blocking' technique when their mind is malfunctioning. I see the mind as either going forward with creative and  life affirming useful processing or going backward with past,  death, loss  and negativity. I see this is a car and that I have to simply change direction so use the prayer or affirmation as a kind of transmission neutral before I can get my mind on a forward track.  My favourite affirmations are 'All Shall be Well, All shall be well, and all manner of things shall be well,'  The Serenity prayer,  or sometimes just repeating the word 'peace' or 'one' as a meditation so well researched by Relaxation Response scientist, Dr. Herbert Benson.

The assumption in CBT is not that "I'm okay and you're not" but rather that I have mental 'skills' and 'techniques' and 'training' that help one's thinking and feeling'.  Change the thinking and behaviour and the feeling follows.  Further by disrupting these repetitive patterns of negative thinking and behaviour and feeling, the general result is a higher more functional form of thinking and feeling.
CBT was originally found to be most effective for mood disorders but has been used in all areas of mental illness with varying levels of efficacy. 
It has been extremely beneficially in treating panic attacks, phobias and a variety of anxiety disorders, though personally I'd say the insight therapies are probably of more long term and deeper benefit.

In addictions, Freud said that alcoholics were essentially untreatable and Jung said they needed a miracle.  Psychoanalytic therapy or "insight' therapy often made alcoholism worse as addicts tend to 'rationalize' and as they explored their personal history found even more reason for drinking. Dr. Jung felt that alcoholism needed a miracle.  Dr. Bob, co founder of Alcoholics Anonymous, said, 'Never deny an alcoholic the consequences of their alcoholism, because they only learn from consequences".  The recognition was that 'right behaviour lead to right thinking" given that MRI and various other evidences today suggests the brain of an alcoholic or addict is hijacked by the disease and therefore can't itself 'self repair' without a period of 'abstinence".  After a period of 'abstinence' there is the possibility that a person will be able to see their own behaviour and their situation from a wholly different perspective than the drug induced 'unreal' or even 'psychotic' perpsective.

Dialectic Behavioural Therapy is a form of CBT that has been found beneficial for personality disorders noting that personality disorders have a long standing pattern of maladaptive behaviour. The original adaption may have been essential at one time in that place but no longer serves a positive purpose. I found this most evidence in long term institutionalized patients whose 'jail house' behaviour had helped them survive but outside of the institution very much interfered with their ability hold jobs and establish relationships.  Dialectics is best consider in the Marxist Lenninist context considering origins but also it's been liked to Socratic method of investigation of the individuals behaviour pattersn. Again the 'rational' and 'cognitive' almost 'education' programing involved in these therapies is at variance to the original psychoanalytic therapy or even the Gestault therapies or Ericksonian models of therapy known to have high efficacy for behaviour change.

Eclectic therapy tends to incorporate a variety of therapies as does traditional and conventional 'supportive' therapies. CBT is commonly seen in this context as opposed t o it's purer more research based form.

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