This is a Dirty Dozen on cognitive behavior therapy (CBT), one of the major psychotherapeutic methods which is effective in a variety of psychiatric disorders. Since 2001, psychiatry residents have been required to learn about it and it has to be a part of their training. Dr. Aaron Beck, MD, is the originator and he’s a psychiatrist. He’s an emeritus professor at The University of Pennsylvania and has been listed as one of the “10 individuals who shaped the face of American Psychiatry”, Department of Psychiatry : Aaron T. Beck, M.D.
When I was a resident, I was required to learn CBT and I was pretty excited about it. In fact, I’m still pretty excited about it because I find myself applying the principles, even in my work as a psychiatric hospitalist. I can’t tell you how many times I’ve seen patients who seemed to be struggling with automatic thoughts and entrenched assumptions or filters. And I’ve recommended the big yellow book, “CBT for Dummies” by Rhena Branch, and Rob Willson, many times to patients I’ve been consulted to see who struggle with both medical illness and a variety of psychiatric disorders.
Slide 3: This is just a bit of historical introduction to CBT and its originator, Dr. Aaron Beck, M.D. He’s a psychiatrist and I believe he just recently passed his 90th birthday and is still going 90 miles an hour. CBT got going in the early 1960s and was actually found to be a better explanation for depression than the psychoanalytic construct, anger turned inward.
Slide 4: CBT is a focused, practical psychotherapy based on the premise that we often feel what we think, and that can lead to unhealthy and even harmful behaviors, creating a vicious cycle which can be linked to a variety of psychiatric disorders. It’s possible to examine our thoughts, test them as hypotheses in behavioral experiments and prove to ourselves that we can learn about the connection between thoughts and feelings and behaviors, see that we’re making choices, and raise our awareness that we can change.
Slide 5: I’ve always liked the practical, goal-directed approach of CBT, though I’ve heard the complaint that it can seem “techniquey” at times. It’s been shown in hundreds of studies to be efficacious in treating a number of psychiatric disorders, even schizophrenia. It has also been studied and found to be effective for the unhelpful thinking, depressive and anxious symptoms, and self-defeating health behaviors seen in a variety of physical illnesses. The video of Dr. Aaron Beck can also be viewed on YouTube and is one of a number of videos that illuminate his vision about CBT. The cognitive triad is foundational in that it presents what we see in the real world, which is that negative and self-defeating thinking tends to cycle amongst views of the self, the world, and the future.
Slide 6: These are some examples of automatic thoughts and schemas, a couple of other foundational assumptions. Automatic thoughts are quick, often absolutistic conclusions, negative self-talk in which we can engage and which hinders us from moving forward in our lives. CBT can help us become more aware of them and facilitate change.
Slide 7: Sometimes it may be difficult to simply stop a thought, so starting with behavioral exercises that begin with action can be effective at getting us out of a rut.
Slide 8: You got to have goals. As Stephen Covey says, “begin with the end in mind.” This means we need to know what we want to accomplish, whether we’re about relieving depression and anxiety symptoms that prevent us from succeeding at work and developing nurturing relationships–or getting on an airplane and getting through the ride without embedding our fingerprints in the arm rests. CBT teaches us to be our own therapists.
Slide 9: The way to help people arrive at their own conclusions independently and engage them in problem-solving is sometimes facilitated by socratic questioning, which avoids spoon-feeding the answers to the person about what choices he or she ought to make. I remember way back when in my Freshman year of college when we were studying the dialogues of Plato and a student was called upon to explain one of them. He obviously had not done his homework and struggled along, repeating this phrase several times: “And then he broke that all down….” Socratic questioning doesn’t have to be that detailed though it tends to be sequential and leads the person to see important themes for herself.
Slide 10: Behavioral methods can be powerful ways to help us gradually adapt to activities that may frighten us and which could help us grow.
Slide 11: This is a selected list of CBT references.
Branch, R. and R. Willson (2010). Cognitive Behavioural Therapy For Dummies, 2nd Edition, John Wiley & Sons, LTD.
Dewan, M. J., MD,, B. N. Steenbarger, PhD,, et al., Eds. (2004). The Art and Science of Brief Psychotherapies: A Practitioner’s Guide. Core Competencies in Psychotherapy. Washington, DC, American Psychiatric Publishing, Inc.
Garland, A., R. Fox, et al. (2002). “Overcoming reduced activity and avoidance: a Five Areas approach.” Advances in Psychiatric Treatment 8(6): 453-462.
Temple, S., PhD, and S. Stuart, MD (2010). Psychotherapy for the hospitalized medically ill patient. Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry. J. J. Amos, M.D., and R. G. Robinson, M.D. New York, Cambridge University Press: 242-248.
Whitfield, G. and C. Williams (2003). “The evidence base for cognitive–behavioural therapy in depression: delivery in busy clinical settings.” Advances in Psychiatric Treatment 9(1): 21-30.
Williams, C. and A. Garland (2002). “A cognitive–behavioural therapy assessment model for use in everyday clinical practice.” Advances in Psychiatric Treatment 8(3): 172-179.
Williams, C. and A. Garland (2002). “Identifying and challenging unhelpful thinking.” Advances in Psychiatric Treatment 8(5): 377-386.
Williams, C., R. Martinez, et al. (2011). “Training the wider workforce in cognitive behavioural self-help: the SPIRIT (Structured Psychosocial InteRventions in Teams) training course.” Behav Cogn Psychother 39(2): 139-149.
Wright, B., C. Williams, et al. (2002). “Using the Five Areas cognitive–behavioural therapy model with psychiatric patients.” Advances in Psychiatric Treatment 8(4): 307-315.
Wright, J. H., MD, PhD,, M. R. Basco, PhD,, et al., Eds. (2006). Learning Cognitive-Behavior Therapy: An Illustrated Guide. Core Competencies in Psychotherapy. Washington, DC, American Psychiatric Publishing, Inc.
Slide 12: These are some web links to resources about CBT.
1. One of the foundational concepts of CBT is:
A. The Big 10
B. The Magnificent 7
C. The Cognitive Triad
D. Ocean’s 11
2. One premise of CBT is:
A. Automatic thoughts can’t be controlled because, hey, they’re automatic
B. We should avoid thinking by watching reality shows
C. If it feels good, just do it.
D. We often feel what we think and that can drive behavior
3. CBT is effective for symptoms of schizophrenia
4. A leading figure in CBT is:
A. Simon Cowell
B. Aaron Beck
C. Sigmund Freud
D. Harry Truman
5. CBT has been effective in the treatment of:
B. Panic Disorder
D. All of the above
CBT Quiz Answer Key:
1. C; 2. D; 3. A; 4. B; 5. D