How is it that you have ended up either consulting or thinking of consulting a cognitive behaviour therapist? How much do you know about CBT? Have you actively sought out a CBT therapist or were you recommended to do so? These are some of the questions that come to my mind as I invite you to decide whether or not CBT is for you. Indeed, these are some of the questions that I do ask people who come to see me, either to consult me as a CBT practitioner or to seek my help to determine which approach to therapy is best suited to them. Since I donât know your answers to these questions, let me deal with the issue of how you can best decide if CBT is for you in a more general way.
Common Factors That Span Different Psychotherapeutic Approaches
In the field of psychotherapy and counselling, it is recognised that different approaches have both common factors (i.e. common to all therapeutic approaches) and specific factors (i.e. specific to the particular approach under consideration). The main common factors include:
- the development and maintenance of an effective working alliance between you and your therapist;
- the provision of a safe space in which you can discuss whatever is important to you;
- the mobilisation of hope whereby you come to see that you can effectively address your concerns; and
- experiencing your therapist as someone who is genuine with you, understands you and accepts you.
As I have said, these factors are common to all approaches to therapy and are not specific to CBT.
While I have entitled this chapter âDecide If CBT Is for You,â when it comes to the presence or absence of these common factors, I suggest that your focus be more on deciding whether or not the therapist whom you have come to see is the right person for you to consult than on whether or not CBT is right for you. Thus, your therapist may be technically proficient in CBT, but if you donât feel safe talking to her1 about what really matters to you, you are right to have doubts about your therapist. Based on the above, here are some questions to ask yourself to help you make your decision about whether or not to work with your particular therapist:
- To what extent does my therapist understand my problems from my perspective?
- To what extent does my therapist accept me the way I am?
- To what extent is my therapist genuine in the way she interacts with me?
- To what extent do I feel safe to discuss what really matters to me with my therapist?
- To what extent does my therapist inspire hope in me that I can effectively deal with my problems?
- To what extent does my therapist foster a working relationship with me focused on dealing with my problems?
While it is unrealistic for your therapist to score top marks on all these points, she should score highly enough for you to consider working with her over time. If she scores poorly on all these points, then, in all probability, she will not be able to help you much despite her proficiency in CBT. If the therapist scores highly on all but one or two points, then you should consider discussing your feelings with her on the points where she does not score highly. I will address the importance of discussing with your therapist matters to do with your therapy later in this book. For now, let me make two points. First, if you donât feel able to discuss your concerns with your therapist, then this may, in itself, indicate that your therapist is not right for you. Second, if you do decide to discuss your concerns with your therapist on these matters, the way your therapist responds is important. If she takes your concerns seriously and responds without defensiveness, then these are good signs that you can work with the therapist and that you can deal with any rifts in your relationship that may occur over the course of therapy. However, if your therapist appears to dismiss your concerns and/or responds defensively, then this does not augur well for the future and you should consider finding yourself a different therapist.
Having made this point, donât forget that therapists are human too and may have their off days. However, if a therapist responds dismissively and or defensively more than once, then I do urge you to think very carefully about continuing to work with that person.
CBTâs Main Specific Factors
In making a decision concerning CBTâs suitability for you, it is important for you to understand some of the therapyâs main features. I made the point in the introduction that CBT is, in fact, a psychotherapy tradition and that there are a number of different approaches that come under the umbrella of the CBT tradition. Having said that, let me outline some of CBTâs main specific factors.
CBT Focuses on the Way You Think and Act in the Context of Your Emotions and in the Situations in Which You Experience These Emotions
CBT stands for âcognitive behaviour therapy,â and thus you would expect that the therapy would focus on cognition and behaviour.
Focus on Behaviour
Letâs start with behaviour, as this is the easiest of the two terms to grasp. Your CBT therapist will focus a lot on the ways in which you behave, particularly in situations in which you experience your problem(s). However, your CBT therapist may also be interested to understand what may be termed âaction tendencies.â These describe situations in which you feel an urge to act in a certain way but donât actually do so. Such action tendencies are particularly valuable in helping your therapist discover your hard-to-identify emotions (such as envy and hurt). Understanding the difference between an action tendency and an overt behaviour may also help you see that you donât have to act on your action tendency, which is particularly important with problems of anger and self-discipline.
The focus on behaviour in CBT is particularly linked to an understanding of your goals and values. Thus, expect your CBT therapist to enquire about the extent to which your problem-related behaviour helps you to meet your goals and to what extent it is consistent with your personally held values. Consequently, during therapy you can expect your therapist to encourage you to act in ways that help you to achieve your goals and are consistent with your values as well as to help you to identify, reflect on and deal with obstacles to the execution of such behaviour.
A particular focus on behaviour that your therapist may well take, particularly if you have problems with anxiety, is to consider your use of safety behaviours (i.e. behaviours which you use to keep yourself safe from threat, but in ways that may serve to maintain your anxiety problems). CBT practice is strongly underpinned by research, and while studies in the past showed the negative effects of such safety behaviours, more recent studies have shown that they may be useful in encouraging you to face your fears. Effective CBT therapists keep abreast of the research literature and modify their practice accordingly.
Focus on Thinking
While the word âcognitiveâ is derived from the Latin verb cognoscere, meaning âto know,â in CBT it is used to refer to your thinking and particularly thinking that has a bearing on how you feel and act. Thinking can occur at different levels of your mind. There is surface-level thinking, which occurs in the form of automatic thoughts (i.e. thoughts that pass through your mind and are easily identifiable) and there is deeper-level thinking, which is less easily identifiable and takes the form of underlying beliefs. CBT therapists may vary in how much emphasis they place on these different levels of thought. If they deal with both levels, they may differ concerning the order in which they focus on them. What is important is that your therapist helps you to understand the role that your thinking (at whatever level) plays in your problems and elicits your agreement concerning how best to deal with them.
Another type of thinking that CBT therapists are interested in concerns where you place your attention when you are experiencing your problems. This is known as your attentional focus and is a useful area for you to explore with your therapist, whatever problems you have, for what you pay attention to tends to be closely related to your behaviour and emotions.
With respect to thinking, a recent development in CBT research and practice has been on ruminations, thoughts that go round and round in your head which you just canât seem to stop. It has been known for many years that such thinking is a key component of worry or generalised anxiety disorder (GAD), but more recently its important role in the perpetuation of depression and unhealthy anger, to take but two examples, has come to be realised.
You should be aware that CBT therapists from different approaches tend to vary concerning how they address your thinking. For example, practitioners of a CBT approach known as rational emotive behaviour therapy (REBT), pioneered by Dr. Albert Ellis, will help you early on in therapy to identify and challenge one or more of four deeper-level unhealthy beliefs (known as irrational beliefs) using arguments designed to encourage you to consider how consistent with reality these beliefs are, how logical they are and how useful they are. These therapists will also help you to construct healthy (or rational) alternatives to these beliefs which are more consistent with reality, more logical and more useful to you.
Other CBT therapists will focus initially on your more accessible surface-level thinking and help you to examine such thinking for its practical utility and to construct more helpful alternative ways of thinking. Later on these therapists, who have been trained in cognitive therapy, pioneered by Dr. Aaron T. Beck, will help you to identify and again examine for their practical utility a deeper set of underlying beliefs known as schemas and to construct more useful schemas. Unlike their REBT colleagues, cognitive therapists consider that the form of such schemas can vary greatly from individual to individual rather than be grouped into one or more of REBTâs quartet of unhealthy (irrational) and healthy (rational) beliefs. Also, cognitive therapists are primarily concerned with the practical utility of thinking, and while they are also concerned with how consistent with reality such thinking is, they are less concerned with the logical status of such thinking.
While I have touched on some differences between REBT therapists and cognitive therapists, both are concerned to help you to focus on thinking that underpins your emotional problems with a view to help you to stand back and respond to it in some way. Other CBT therapists believe that encouraging you to respond to such thinking only results in you getting increasingly caught up in such thinking and may unwittingly help you to ruminate. For these therapists, who practise a form of CBT known as acceptance and commitment therapy (ACT), problem-related thinking is best dealt with by your accepting its existence without engaging with such thoughts (e.g. by challenging them) and by committing yourself to value-based behaviour despite the presence of these thoughts in your mind. These therapists do not speak of thoughts being distorted or realistic or beliefs being irrational or rational because they consider thoughts to be very much influenced by the context in which you find yourself rather than by the realistic or rational status of the thoughts.
From a therapeutic point of view rather than a scientific perspective, what really matters is whether the explanation provided to you by your CBT therapist concerning the role your thinking plays in your problems and what to do about it makes sense to you and whether you are prepared to proceed with a therapy that is based on these ideas. That is why it is so important in CBT for the therapist to be transparent in explaining her position on these issues to you.
CBT Focuses on How You Unwittingly Maintain Your Problems Rather Than on How They Originally Began. Consequently, CBT Focuses on What You Can Do Now to Address Your Problems
It is often thought that CBT therapists are not interested in your past. This is not correct, and in CBT you may talk about whatever it is you are bothered about, be it your past, your present or your future. Having said this, CBT therapists tend not to believe that helping you to understand the past roots of your present problems will be curative in the long term without you doing something about these problems in the present. CBT therapists generally hold to the view that relevant past experiences may have contributed to your current problems but do not account fully for these problems. CBT therapists explain this by pointing out that if 100 people all experienced exactly the same past experiences as you, not all of them would have developed the same problems as you. Some may have developed other problems and others would not have developed problems at all. Rather, it is the views you took from these experiences and still hold currently that largely account for your problems together with the behaviour that stems from these views.
For example, take the problem of jealousy. If you have such a problem, it may well be the case that you felt jealous of your sibling as a child. However, this insight will not help you if you continue to act in jealous ways in the present (e.g. by preventing your partner from doing things, checking on his or her whereabouts). Such behaviour will reinforce and strengthen the beliefs that underpin your jealous feelings and will nullify any effect that insight into the possible roots of your problem might have. As a result, unless your CBT therapist helps you to deal with the ways in which you currently, but unwittingly, maintain your problem, then it is unlikely that you will gain much long-term benefit from therapy.
CBT Focuses on Helping You to Put Into Practice Between Sessions What You Learn in Sessions
When you consult a CBT therapist, it is unlikely that you will derive any benefit unless you learn something in the therapy sessions. However, such learning is likely to be academic and thus of limited value to you unless you put it into practice between therapy sessions. Consequently, in CBT, expect your therapist to negotiate with you on ways of implementing your session-derived insights into relevant situations in your everyday life. The extent to which you do so will determine how much you get from CBT. Thus, I am often asked whether CBT is helpful. What is my answer? Yes, if you use it; no, if you donât! I will discuss the issue of applying what you learn in Chapter 6.
CBT Focuses on Helping You to Become Your Own CBT Therapist
While all approaches to counselling and psychotherapy have as an aim you learning how to help yourself in the future after therapy has ended, CBT therapists, more than other practitioners, implement this aim in specific ways. They do this by teaching their clients CBT self-help skills throughout the therapy process. Thus, your therapist may well use a CBT-related framework to teach you how to assess your own problematic thinking, feeling and behaviour in problem-related episodes and how to respond productively to these situations. You will then be encouraged to use this framework for yourself between sessions and helped to refine your developing skills in subsequent sessions by your t...
