Concepts, Principles and Techniques of Cognitive Behavioural Therapy (CBT) for Depression, Anxiety and Other Conditions
Cognitive behaviour therapy (CBT) was initially devised as therapy for depression. It emerged in the 1960s, when two influential schools of thought in psychological science–cognitive theory and behavioural theory, united to form a powerful intervention. CBT later became applicable to a wide range of disorders and conditions, such as
- depression,
- anxiety conditions, including panic attacks,
- binge eating disorder,
- compulsive behaviour,
- personality disorders,
- anger control issues
- self-esteem issues
- relationship and couples problems
To date, CBT holds the most substantial evidence base compared to other psychological interventions.
The Cognitive Part of CBT
This segment of cognitive behavioural therapy addresses thoughts and interpretations of particular situations. It involves training in specific skills so that people can learn to improve their mood and change behaviour by altering how they think about situations. A thought record is a main tool for identifying and examining the associations between thoughts, feelings and behaviours.
Cognition is the mental process of thinking, reasoning, perceiving, remembering, evaluating and imagining. CBT posits that our emotions and behaviours result from our thoughts about ourselves, people and the world. However, sometimes our interpretations contain distortions, errors or biases and are simply unhelpful and dysfunctional, and this, as a rule, leads to suffering or other self-defeating reactions. For instance, in individuals with depression, a negative way of inferring about events and expectations triggers depressive behaviour, promoting feelings of inadequacy, low self-esteem and hopelessness.
Cognitive techniques focus on learning to become better aware of our cognitions and alter them when distorted and unhelpful. The focus of cognitive interventions is identifying and altering distorted thoughts and unreasonable cognitive schemas implied in generating and maintaining depression, anxiety, binge eating disorder, panic attacks, dependencies, personality disorders, anger management issues and other conditions.
The Behavioural Part of CBT
This segment of CBT addresses the influence of behaviour on the emotional state. The target of the therapist’s work in this part of the therapy is to increase the patient’s behaviours that may improve their emotional state and lessen behaviours that lead to a negative mindset. In CBT, the therapist assists the client in identifying which behaviours are maintaining the problem, and which behaviours can help produce positive changes.
Behavioural Activation (BA) in Cognitive Behaviour Therapy (CBT) for Depression
Behavioural activation (BA) is a core aspect of cognitive behaviour therapy for depression. Depression often leads individuals to progressively detach from their regular routines and isolate themselves from their surroundings. Subsequently, withdrawal has a compounding effect on their depressive state, as they miss out on opportunities to experience positive reinforcement through enjoyable moments, social interactions, and a sense of mastery.
Behavioural activation is an approach that aims to enhance the individual’s exposure to rewarding experiences by facilitating increased engagement in activities. It involves identifying values that can guide the selection of activities and focus on increasing engagement in those activities. Furthermore, BA in CBT for depression addresses the processes that hinder activation or promote avoidance, while teaching problem-solving skills.
Exposure Therapy in CBT for Anxiety
Similarly, inducing behavioural change is crucial for tackling anxiety and fear. The main characteristic of anxiety disorders is avoidance, which, in fact, perpetuates the fear of feared situations. Avoidance can be either of actual situations or internal experiences, such as emotions and memories. This keeps people maintaining their old dysfunctional patterns, as avoidance impedes new learning that can invalidate distorted negative beliefs about oneself, others and the world. In addition, avoidance prevents people from experiencing satisfaction and motivation. In CBT, the therapist and client collaboratively look for new behaviours for the client to gradually overcome this avoidance. Consequently, exposure to feared situations or stimuli gradually and safely is a primary means of treating anxiety. Behavioural strategies for anxiety are focused on increasing exposure, expanding activity, enhancing social skills and facilitating tolerance of uncertainty, which complement the effects of cognitive techniques.
Similar to the cognitive part, the assumption here is that changing our behaviours can change our feelings and thoughts.
The Beck’s Cognitive Model
The idea of cognitive therapy was elaborated in 1960 by a pioneer of CBT Dr Aaron Beck, a psychiatrist at the University of Pennsylvania. He studied and practised psychoanalysis and carried out many trials related to therapy for depression. Beck’s increasing interest in cognition developed during his experience as a psychoanalyst. He was disappointed in psychoanalytical considerations of depression and started exploring the role of the negative thoughts, which he detected in depressed individuals.
His cognitive model is the foundation of cognitive therapy. It hypothesises that peoples’ emotions and behaviours are influenced by their perception of events.
It is not the situation per se that determines what people feel. Rather, it is how we interpret this situation.
As depicted in the picture below (Figure 1), the event does not directly determine our feelings. Our perception of the situation mediates our emotional response.
The cognitive model is the cornerstone of CBT. Cognitive behavioural therapy for depression, anxiety, panic attacks, binge eating, personality disorders and anger management issues applies the cognitive model to tackle maladaptive cognition and behaviour. The main concepts relevant to the cognitive model include
- negative automatic thoughts,
- cognitive distortions that sustain them,
- core beliefs and schemas with the negative cognitive triad that underpins them,
- behavioural reactions, such as withdrawal, avoidance or safety behaviours.
The Structure of Maladaptive Cognition
According to Beck (1976), maladaptive cognition comprises three parts –
- core beliefs,
- dysfunctional assumptions and
- negative automatic thoughts (NATs).
Online or In-Person Cognitive Behaviour Therapy for Depression and Other Conditions: Identifying Core Beliefs
Negative core beliefs, or schemas, are profound beliefs about self, others and the world. These schemas are typically formed early in life and refer to a particular cognitive construct, such as “people can’t be trusted” or “I’m worthless”. Those are just ideas and perceiving them intensively does not make them more than just beliefs. Core beliefs start emerging in childhood and are held for a long time because a person has stored some evidence that maintains these beliefs and rejected evidence to dispute them. Through the techniques taught in therapy, these negative beliefs can be verified and changed.
Negative core beliefs underly dysfunctional behaviours and thoughts. Thus, it is necessary to identify and challenge these beliefs during therapy. Core beliefs are fixed in schemas, which comprise the cognitive triad. These are three schemas operating simultaneously to make appraisals of life events and produce responses.
CBT: Cognitive Triad
According to Beck, the cognitive triad (Figure 2) consists of negative views about oneself when the person tends to see themselves as inadequate or inept (e.g. “I am a boring person“, “I am uninteresting“, “I am too sad for anyone to like me“), a negative view about the world, including relationships, work and activities (e.g. “No one appreciates my job“, “Everyone hates me“) and negative views about the future, which are linked to the degree of hopelessness and typically include the desperate thoughts such as “Things are never going to get any better“, “I’ll never be happy“, etc.
CBT: Dysfunctional Assumptions
Those rigid assumptions are inflexible “rules for living” that people develop and hold, often in the form of expectations. For example, one may live by the rule, “It’s better not to start because I can fail”. The rigid rules are the intermediate thoughts between core beliefs and hot thoughts of negative automatic thoughts (NATs).
CBT: Negative Automatic Thoughts (NATs)
These kinds of thoughts are automatically activated in people’s minds rather than reasonably reflecting the situation. In depression, NATs typically focus on low self-esteem and hopelessness, as, for example, when failing a test, the NAT may be, “I am worthless, I’ll never pass”.
Automatic thoughts arise from the core beliefs – the ideas that people develop about themselves, others and the world, beginning in childhood. Core beliefs are rigid and over-generalised. However, this belief may operate only when the person is in a depressed (anxious or other pathological state) state. As the notion implies, automatic thoughts occur automatically, however, these thoughts are situation specific.
Negative automatic thoughts are underpinned by cognitive distortions such as overgeneralisation, personalisation, labelling, all-or-nothing thinking, mental filtering, maximisation and minimisation, emotional reasoning and labelling.
CBT: Cognitive Distortions (Thinking Errors)
Thinking errors or cognitive distortions are one more principal concept of cognitive-behavioural therapy that refers to biased ways of thinking about oneself and the world around us. Cognitive distortions are patterns of unhelpful thinking that often occur automatically and cause us to perceive reality irrationally. Everyone encounters thinking errors to some degree. Yet, in their more extreme forms, those errors can harm.
Cognitive distortions can cause disturbing emotional states and behaviour, like depression, anxiety, low self-esteem and relationship conflicts. Therefore, it is necessary to be aware of them to be able to shift irrational and destructive thinking to more rational and helpful ones.
Some common cognitive distortions are the following:
All-or-nothing thinking: Adopting extreme viewpoints instead of considering a range of possibilities. For example, believing that being a bad parent is the only explanation for your child’s misbehaviour.
Catastrophising: Expecting only negative outcomes in the future. For example, thinking that failing a final exam would completely ruin your life.
Disqualifying or discounting the positive: Disregarding or downplaying positive experiences or compliments.
Emotional reasoning: Letting emotions override objective facts.
Labelling: Assigning labels to people or things without seeking additional information.
Jumping to conclusions: Making hasty judgments based on limited or incomplete evidence. For example, immediately assuming someone has bad intentions upon seeing them without having sufficient information to support that conclusion.
Magnification/minimisation: Exaggerating negatives or minimising positives in a situation.
Mental filter/tunnel vision: Focusing only on the negatives in a situation and disregarding any positives. For example, assuming you are a lousy wife solely based on your husband’s comment about housekeeping.
Mind reading: Believing you know what others are thinking without any evidence. For example, assuming that your friends think you are a slob because your house was dirty when they visited.
Overgeneralisation: Drawing broad negative conclusions based on isolated incidents. For instance, assuming your husband doesn’t love you anymore just because he didn’t kiss you once.
Personalisation: Assuming that the negative behaviour of others is a reflection of something you did. For example, thinking you upset your friend because they have been quiet.
“Should” and “must” statements: Holding rigid expectations about how people should behave.
The Process of Cognitive Behaviour Therapy (CBT) for Depression, Anxiety, Binge Eating, Anger Control, Self-Esteem and Other Concerns
Socialising to the CBT model
The initial step of the therapy aims to present the CBT model to a client and emphasise the interrelationship between our thoughts, feelings and behaviours and how vicious cycles maintain our problems.
At the beginning of a therapy process, a cognitive behavioural therapist typically applies real examples from the client’s life to the blank hot cross bun model (Figure 3), filling in the model in writing. This facilitates understanding the client’s difficulties and the treatment plan. Furthermore, the client can clearly see how thoughts, feelings and behaviours are interrelated and how they create a vicious cycle that perpetuates depression, anxiety, anger, low self-esteem, relationship problems, etc. Yet, the good news is that, in much the same way, changing thoughts can kickstart an overall improvement in the situation.
Outlining the CBT Techniques
Along with explaining the cognitive model, a CBT therapist may also outline the key CBT techniques:
- Identifying negative automatic thoughts and cognitive distortions,
- Challenging and replacing negative automatic thoughts (NATs),
- Behavioural experiments,
- Identifying and challenging core beliefs (schemas),
- Behavioural activation/inducing behavioural change/exposure therapy.
Homework
Homework assignments play a crucial role in cognitive-behavioural therapy (CBT), as therapy sessions have limited time. Assignments such as readings, behaviour monitoring, and practising new skills are essential to be performed outside of sessions. Homework serves as a valuable tool to support therapy progress, including skill acquisition, treatment compliance and symptom reduction. Thus, by applying the concepts learned in therapy to daily life, individuals can actively engage in their own treatment process.
Relaxation Practices
Relaxation techniques aim to reduce tension, stress, worry and anxiety. The focus of relaxation techniques can vary, addressing physical sensations or changes in cognition and thoughts. The specific practices can be tailored to the individual’s presenting difficulties and preferences. Some individuals respond better to physiologically based practises, such as muscle relaxation or deep breathing, while others prefer guided imagery. By alleviating distress, all these techniques enhance treatment outcomes, build rapport and increase self-efficacy.
Progressive Muscle Relaxation (PMR)
PMR involves learning to sequentially tense and relax different muscle groups while paying close attention to associated sensations of tension and relaxation. This technique has gained popularity for addressing anxiety and panic attacks, helping individuals learn to relax, recognise tension in the body, and reduce its impact. Practising PMR skills regularly outside therapy sessions, at least once a day in the initial weeks, is crucial for skill development and confidence building. Once individuals become proficient in relaxation within calm environments, they can apply these skills in more distracting situations.
Deep breathing
This technique is one more physiologically based relaxation method, aiming to counteract rapid and shallow breathing often associated with stress, worry or anxiety. Rapid and shallow breathing is a maladaptive breathing pattern that can lead to decreased oxygen levels, resulting in hyperventilation, dizziness and reduced concentration. Conversely, deep, full breaths promote a sense of calmness by increasing oxygen flow in the bloodstream. Deep breathing is recommended for practice outside therapy sessions, particularly when individuals feel stressed.
Imagery
It is a cognitively based relaxation technique that involves changing the focus of one’s thoughts to promote cognitive, emotional and physical control. Similar to daydreaming about pleasant experiences, imagery fosters positive “dreaming” that distracts and relaxes the individual. This technique helps alleviate symptoms of depression and anxiety and can be beneficial in situations that require clarity, concentration or distraction from negative thoughts.
Cognitive Behaviour Therapy (CBT) for Depression, Anxiety, Binge Eating, Anger Issues, Self-Esteem and Other Concerns: Conclusion
CBT: Application
Cognitive-behavioural therapy (CBT) is a powerful intervention developed in the 1960s, combining cognitive and behavioural theories. CBT has been extensively researched and has shown effectiveness in treating various mental health conditions, including
- depression,
- anxiety,
- panic attacks,
- binge eating and other eating disorders,
- dependencies,
- personality disorders,
- anger management,
- relationship problems,
- self-esteem and other concerns.
CBT focuses on the interrelation between thoughts, feelings and behaviours.
The Cognitive Aspect of CBT
It involves training individuals to improve their emotional state and change their behaviour by altering their interpretations of situations. A key tool used is the thought record, which helps identify the connections between thoughts, feelings, and behaviours.
The Behavioural Aspect of CBT
It addresses the influence of behaviour on mood and focuses on increasing positive behaviours and reducing negative ones. Behavioural activation is an important component of CBT for depression, and exposure techniques are used to treat anxiety.
CBT Techniques
Cognitive behaviour therapy (CBT) for depression, anxiety, panic attacks, compulsive behaviours, personality disorders, anger and self-esteem issues is a course of teaching, coaching and reinforcing rational behaviours. Conitive-behavioural interventions include identifying and challenging negative thoughts and core beliefs and replacing them with more rational alternatives to produce behavioural changes. In addition, homework assignments and practising relaxation techniques are integral to the therapy process.
Online or In-Peson Cognitive Behaviour Therapy (CBT) for Depression and Anxiety: a “Gold Standard”
Cognitive behavioural therapy for depression and other conditions is considered a “gold standard” in psychotherapy due to its empirical foundation and effectiveness in treating various conditions.
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