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What
is Cognitive Behavioural Therapy (CBT)?
Cognition (to
cognise) means “to possess knowledge or information about”. Re-cognise
therefore means to know again. In practice the word cognition is
also used to mean “to think” or to perceive (in a certain way).
The way you cognise something is the way you perceive (or know) it.
Cognitive Behavioural Therapy therefore is a therapy based on
cognition (knowing) and behaviour, hence the title. At it’s
simplest it can be understood as being based on the understanding
that human beings can think, feel, and behave irrationally and
inflexibly. Here, the word “inflexibly” doesn’t imply being
difficult or awkward, but refers to perceiving in a fixed way,
without the possibility of using alternative perspectives. Having
irrational beliefs, thoughts, and feelings can lead us to perceive
the world through negatively skewed fixed perceptual filters and the
resulting distorted cognition can make us feel (mistakenly) awful
about ourselves, the world, and other people. In the same way that
we can see things through “rose tinted spectacles” when we’re
overly optimistic, we can also see things as being more threatening
than they really are if our perceptual filters are negatively
focused or distorted. Irrational and inflexible thinking creates
disturbance at the emotional and mental level, because perceiving
negatively means we find the World threatening, and this can
inappropriately activate our fight and flight mechanism. This
emotional and mental disturbance can be highly stressful, and can
lead to symptoms of anxiety, depression, anger, sexual dysfunction,
phobias, social anxiety, loss of confidence, fear of the World, low
self esteem, perfectionism, irritation, jealousy, obsession,
compulsion, impatience with others….the list goes on. Cognitive
Behavioural Therapy might be thought of at core then as learning how
to be aware of anxiety causing perceptions and how then to use this
awareness to maintain ongoing positive mental hygiene, thus reducing
anxiety and all its associated symptoms. Once learned, it will be
with you as a strategy for life.
How
does negative perception cause emotional disturbance?
CBT recognises that belief, thought, emotion, and behaviour all
interact with, and affect, each other. What we believe affects the
way that we feel and think. How we think affects the way that we
feel. How we behave (as a result of thinking and feeling a certain
way) then reinforces what we believe, what we feel, and how we
think! Don’t worry, it’s not as complicated as it sounds. CBT is
simply about learning to perceive and behave with flexibility,
learning to minimise your levels of “reaction” (different from
response), and to respond with an extended awareness of your
options.
Essentially, we, as human beings, naturally tend to believe that if
we feel something, or think something then it must be true. It’s
simply not questioned, especially if our experience has told us that
our perception is correct. If we live with a certain belief, we then
go on to act and behave automatically as though that feeling or
thought is absolutely true. In other words we assume that feelings
and thoughts are facts, when in actuality they are often subjective
interpretations of the facts based on our own personal beliefs and
perceptual filters. Put simply, perceptions are by nature highly
subjective (i.e not everyone would feel the same way about it). If
it just so happens that the thought or feeling we are experiencing
is negatively focused, then it usually creates fear, tension, worry,
and stress. Though there may well be some truth to our assessment of
the situation, a more objective evaluation will often reveal to us
that a situation or perception is rarely as absolute as we perceive
it to be, and that we actually have more options available to us
than we are currently perceiving. These options can take the form of
behaving differently, or thinking differently. Often we don’t
perceive these options because in a stressed or un-resourceful state
we can mistakenly “buy into” or “endorse” the
feelings/thoughts/belief/s exactly as they present to us, and they
can cause us to “react” rather than “respond”. Reaction is
instinctive. Response is thoughtful and deliberate. Reacting can
leave us feeling as though we had no other choice and this in turn
can leave us feeling very stuck or emotionally/mentally disturbed.
As an example we know that depression for instance is triggered
partly by a feeling of “helplessness”. If our thoughts tell us
“there’s no way out” then this perception can contribute to or
sustain a depressed state. The assumption that “there’s no way
out” is clearly only a perception, not a fact, and yet it can feel
very true when there appears to be no evidence to the contrary.
Obviously, believing we are eternally stuck in an unpleasant world
(this is in fact what “there’s no way out” tells your
subconscious mind about your life!), will be a very disturbing
perception when we believe it absolutely as if it were a fact. If we
can become aware of contrary evidence we’re on our way to finding
a way out!
How
does CBT work?
CBT sets out look for
evidence, both for and against the negative cognitions and
then offers tools to go about integrating that evidence so as to
think more critically (rationally) about our perceptions, thus
reducing the level of disturbance such perceptions can cause. We
then go on to learn to behave in accordance with our new more
adaptive understanding, which over time, through repetition and
continued thought/belief/behavioural adjustment helps us to feel
differently (less stuck or disturbed). CBT does not talk about good
and bad, or right and wrong thinking/feeling/behaviour. In fact CBT
is deliciously free of such thinking. It is not a “moral”
therapy. It doesn’t ask whether it’s “right” to think or
believe a certain thing or not. It simply looks at whether it’s
HELPFUL to feel or believe a certain thing or indeed to behave in a
certain way. This is known then as adaptive (helpful), or
maladaptive (unhelpful) perception.
The
Insights
Paraphrased,
Albert Ellis’s insights (part of the foundation of CBT)
state the following:
Insight 1 – How you feel is mainly determined by the way you
think. – This notes that the beliefs you carry and action
with feeling become your living emotional reality.
Insight 2 – You become distressed when you endorse your own
irrational beliefs – This notes that those beliefs that create
unpleasant feelings will distress you when you “buy in” to them
without challenging the assumptions by seeing different options of
thinking and perceiving.
Insight 3 – Be kind to yourself. You, like many people, can think
irrationally so don’t judge yourself too harshly – This notes
that CBT is not a self blame exercise…everyone thinks irrationally
sometimes…it’s not right or wrong…so one can be kind to
oneself whilst adjusting thoughts and behaviours appropriately for
easier feelings.
Insight 4 – You have to make a sustained effort to recognise and
challenge your irrational thoughts- This notes that effort is
required over a sustained period of time to make the above
adjustments. Years of ground- in negative perceptions take time to
adjust! Patience and persistence is necessary but there is a pay
off!
The
Therapy
Typically, CBT is a
longer term therapy than Solution Focused Brief Therapy. It usually
lasts anywhere from about six to thirty weekly or fortnightly
sessions. Some CBT therapists work to a sixteen session
standard. This is a “one size fits all” approach which means
that everyone knows where the therapy begins, continues, and ends,
giving a nice clear focus to the client and therapist alike to
complete the therapy. As with all good therapy, CBT is goal
oriented, reflective, methodical, evidence-based, and time-limited.
In plain English this means we want to see the results and we want
to reflect as we go on each stage of the progression towards
wellness and understanding. You can think of it as moving
methodically towards symptom resolution in stages of understanding
and application. CBT is very much a learning and brain re-training
process. Central to the CBT approach is the understanding of exactly
HOW we go about thinking irrationally. When we can identify skewed
perceptions as they arise within us, we are much better equipped to
stop any internal endorsement (buy-in) of irrational disturbing
perceptions before they occur. The following describe some of the
best known perceptual distortions that occur in thinking: -
All or nothing thinking
This is “absolute” thinking. Here, if something is less than
perfect, then it’s seen as all bad! If we can’t do it/ have it
all, then it’s not worth trying. This can create feelings of being
overwhelmed. Chunking down is the process whereby we tackle things
in bite-size chunks, which often makes them appear much more
manageable, and recognise too that maybe we can do SOME of it if not
ALL of it.
Over-generalisation
Characterised
by using the words "always" or "never". This one
creates feelings of being consistently defeated and creates a
negative feeling about the World, Self, and Others. It is RARELY
based on FACT. To overcome over-generalisation we look for
exceptions to these internal assertions.
Mental filter
This filter
involves filtering out whatever doesn’t “fit” ones beliefs,
and looking ONLY for evidence that supports your way of seeing
things, even if that’s purely negative. Usually this means
dwelling on a single negative detail and excluding all else!
Extreme fundamentalism is an easily recogniseable symptom of this
kind of thought distortion, and good evidence to remind us how deep
it can run in some people!
Discounting
the positive
Can you accept a compliment? Can you give yourself a pat on the back
for something you did well? This one involves being able to discount
the twenty people you helped today because one person had a
complaint! (justified or not). You reason that the rest don’t
count because anyone could have done your job and they were just
being nice because they felt sorry for you anyway! Situationally
too, we can discount the positive when one thing isn’t right.
Jumping to conclusions
We already KNOW what they meant with that comment! Do you? Really?
Did you check? This is the “mind reading trick” and can be so
useful in reminding yourself how hostile the World is (even when
your friend was innocent!), because it’s great for not having to
see that everyone is NOT out to get you! If you already KNOW what
someone means then there’s no possibility you might have
misunderstood right? Angry people can go a whole lifetime doing this
one….Never knowing that most people are quite nice and quite like
you when you speak to them kindly.
Negative Forecasting
Forecasting that the future (events and general) will be awful is a
massive cause of stress. Since your brain is the most powerful
future experience rehearsal machine in the World, your poor old (not
so logical) subconscious mind gets very worried indeed when you
negatively rehearse the future as a frightening destination! When
you tell yourself that things will turn our badly, you create fear
and stress. Then, because you’re so stressed and fearful, your
performance drops; everything turns out badly, and you say “See! I
told you so!” Then whole cycle then begins again, but reinforced
because it did in fact go as badly as you imagined. Ironically
that’s because you imagined it going badly first!
Magnification or maximisation (Gonna have my problems to the
size of a cow!)
Exaggerating your problems and shortcomings so everyone (and you)
knows how helpless or useless you are. If you’re already useless
then at least you can’t fall any further right? Magnifying your
negative qualities is the surest way to stay in self judgement and
out of learning to love yourself …warts and all. Also magnifying
your problems makes your life look to you completely unmanageable
and creates feelings of hopelessness. Still at least if you’re
hopeless there’s no point trying right? It could be thought of as
being in “victim” mode. Maximisation is often connected
therefore to a fear of success or paradoxically a fear of failure.
Maximisation creates inaction. It encourages you to remain stuck and
disempowered. The subconscious mind often prefers the familiar but
unpleasant to the unfamiliar and potentially more adaptive. Familiar
is considered safe even if it hurts!
Catastrophising
This is like magnification but comes with a whipped cream topping of
drama. Catastrophising means seeing negative events, people, or
mistakes as absolutely and quite unbearably awful; it is often also
therefore called “awfulising”. This is a very important
distortion to understand in CBT because how we “choose” to see
event’s dictates how we feel about them subjectively. We all have
to deal with unpleasantness sometimes. It’s MUCH easier if we can
learn to deal with it courageously and with dignity and not like a
drama queen or a “victim” (poor me). Catastrophising is perhaps
the most direct way to ensure you directly and needlessly disturb
yourself!
Minimisation
Playing down your strengths – No matter what the evidence is that
you have good qualities…you just can’t/won’t see/believe it!
Emotional
reasoning
I FEEL it
therefore it MUST be true. Feelings are facts and to hell with the
truth!
Should,
must, ought to, have to etc statements –Musterbatory language.
Inflexible
language. When you say something “should” be a certain way, you
are guaranteed to feel disturbed when it’s not! The same goes for
have to, ought to, must etc. This language can be directed towards
yourself and is even more powerfully disturbing when directed
towards the world or others! “Should” is the surest way to
ensure you don’t. “Should” is also the surest way to get
someone else into a defensive stance. “Shoulds” can be easily
replaced with “I’d prefer”, or “I’d like to”. Stop
“shoulding” all over yourself! Can’t is pretty inflexible too!
Negative
labelling
This refers
to labelling self or others as exclusively negative. So rather than
knowing that no-one is perfect we can over-generalise a person’s
behaviour or thinking as bad and label that person a failure or a
jerk. This is inflexible thinking and can be directed towards self,
creating terrible feelings of low self worth!
Personalisation
and blame
A big one in
CBT. We personalise that which is often out of our control. When an
event happens that is beyond our control (illness. missed
opportunities etc) we blame ourselves. This makes you feel rotten
about yourself! Perfectionism can often fall into this category.
Blame is the
opposite of course where we are unwilling to assume responsibility
for our lives and behaviour and thus never arrive at a place of
healing because how can we heal it if we don’t own it? Blaming
also makes you mad at everyone else (creates anger) and blocks
solutions in a big way!
The
History of CBT
Although CBT
has been influenced by Buddhism and Science alike through the years,
perhaps the most interesting individual historical contributors are
Marcus Aurelius, Epictetus, and Immanuel Kant.
Marcus
Aurelis (121-180AD) was a Roman Emperor. He was the author of a
classic philosophical text called “Meditations”. Centrally he is
quoted as saying “If you are distressed by anything external, the
pain is not due to the thing itself but to your own estimate of it;
and this you have the power to revoke at any moment”. This idea
that we can choose how to respond to situations and events is of
course front and centre to CBT.
Epictetus
(55-135AD) was a slave and endured great hardship. His
“master” would often torture him and on one occasion, during a
leg twisting torture session, Epictetus warned his master that the
leg would break. The message was not heeded and the leg broke,
leaving Epictetus lame. Epictetus is quoted: “Some things are up
to us and some things are not. Our opinions are up to us, and our
impulses, desires, aversions – in short, whatever is our own
doing. Our bodies are not up to us, nor are our possessions, our
reputations….that is, whatever is not our own doing”
Although this
message is perhaps less relevant to most people’s situation today,
the central theme, that being that there are factors in life beyond
our control such as other people, and their opinions, remains highly
relevant to CBT. In essence there are many things we can’t control
in life, but he notes we can choose to control how we respond to
those things.
Immanuel
Kant (1724-1804) – Immanuel Kant basically proposed that
objectivity (the real world) is ultimately imperceptible to the
individual. He explained that all experience is filtered through
subjective filters, named schema. This also is central to CBT. In
understanding that what we experience is an “interpretation” of
events rather than a “fact”, we can easily find our way back to
the CBT based understanding that what we “feel” (our filtered
interpretation) about something doesn’t always match the
“facts” of the situation.
The
Process.
So now, you
can probably begin to see how CBT works? The problem is that we are
often in the habit of thinking in these distorted ways
without conscious awareness of doing so. CBT uses many different
techniques to bring a new awareness to these patterns. A discussion
of the techniques used are beyond the scope of this article, but a
central technique is to use a “Thought Record”. A thought record
asks you to record exactly where you are, who you’re with, and
what you are doing at the moment that your mood shifts from positive
to negative, and then to write down your thoughts exactly as they
occur at that moment. Having identified those central “disturbing,
maladaptive” thoughts and beliefs, we can go about providing
more adaptive perspectives. This process is collaborative, meaning
that the therapist guides you towards a better understanding of how
you may be distorting your perceptions and we work together then to
create new more helpful perspectives that you can buy into with
feeling. Alongside this, we work on core beliefs, because if a core
belief is negative then it can create LOTS of negative thoughts in
many different situations. A core belief that says essentially
“I’m no good at anything” will affect everything you do
negatively. Using thought records and other CBT tools, we can
quickly trace back to the roots and find the core belief. There are
many other tools we use in CBT including clinical rating scales,
thought diaries, activity schedules, formal goal setting, graded
exposure tasks, cost to benefit analyses, behavioural
experimentation, and many more. These processes give great structure
to the process and allow us to evaluate our successes and
accomplishments as we gain them, thus giving you increasing
confidence and evidence in your ability to live from new beliefs and
step into empowerment.
Cognitive
Behavioural Hypnotherapy
Cognitive
Behavioural Hypnotherapy makes total sense! It always has to me.
Firstly a few snippets of research for you:
Smith et
al. (1984) pooled the results of 475 controlled studies into the
efficacy of different modes of therapy. The results showed that
Cognitive Behavioural Therapy, systematic desensitisation, and
hypnotherapy performed “better than average” in achieving
therapeutic improvement, where average was defined as the mean
outcome of all therapies studied.
The
international journal of Clinical and Experimental Hypnosis 2007
conducted a study of 84 depressed persons using 16 weekly treatments
of CBH versus CBT alone. The results showed that CBT combined with
hypnotherapy produced a greater improvement in anxiety by 5%,
hopelessness by 8% and depression by 6% than if CBT were used alone,
demonstrating clearly that CBH could be highly effective as a
treatment model.
The
British Medical Journal published studies in 2005 finding that in
one study of 30 people presenting with severe IBS, that treatments
using hypnotherapy alongside CBT were more effective than in the
non-hypnotherapy control group. The 15 patients from the
hypnotherapy group were followed up over the next 18 months and it
was found that all patients had remained in remission.
These results don’t surprise
me at all. The National Institute for Health and Clinical Excellence
(NICE) is the independent organisation responsible for providing
national guidance on the promotion of good health and the prevention
and treatment of ill health. CBT is recommended by NICE as an
effective evidence based therapeutic methodology. In plain English
this means it’s mainstream (it is used within the NHS) and has
been proven in trials as highly effective.
The Royal College of
Psychiatrists tell us:
http://www.rcpsych.ac.uk/mentalhealthinformation/therapies/cognitivebehaviouraltherapy.aspx
How effective is CBT?
§
It is one of the most effective treatments for conditions where
anxiety or depression is the main problem
§
It is the most effective psychological treatment for moderate and
severe depression
§
It is as effective as antidepressants for many types of depression
In short then, CBT is
effective, and research is showing, what we as practicing
hypnotherapists have always known; that cognitive behavioural
hypnotherapy is even more effective. Let’s have a look at why.
Why
Cognitive Behavioural Hypnotherapy?
We know that negative thinking
arises from what are known as “Schema” or “Schemata” (plural
schema). Schemata is the term used to describe the perceptual
filters I have been talking about. Schemata are based on core
beliefs. Hypnotherapy has always been about helping people to change
their core beliefs by communicating directly with the unconscious
mind. You can find plenty of information about this on my website,
but essentially, we know that we can change core beliefs much more
quickly and to a greater depth when we go straight to the source.
That is to say, using hypnotherapy, we can communicate these more
adaptive cognitions directly to the unconscious mind, thus bypassing
the usual “resistance” of the conscious mind. The unconscious
mind of course is where your core beliefs reside. This is the
central computer from which all thinking, feeling, and behaviour
springs. Since CBT is primarily a conscious mind technique, we have
a major advantage when using CBT combined with hypnotherapy, because
conscious mind adjustment is a slow process. It’s effective, and
often necessary, but it’s like a drip feed when it comes to
relaying information back to the unconscious. The message of change
is only slowly absorbed when you work purely at the conscious mind
level, and then only by persistence and repetition. Since
hypnotherapy operates at a much more visceral (subconscious) level,
we can amend belief systems quickly, and these belief systems are at
the core of your thinking. Change the belief at the
unconscious level and you simply FEEL, THINK, and BEHAVE
differently. Therefore, whilst CBT can give great structure to the
therapeutic process, hypnotherapy can help to deliver the necessary
perceptual adjustments much more directly. In many ways then the two
therapies compliment each other perfectly. Having access to both
therapies also places us at a considerable advantage when it comes
to addressing the individual components of a difficulty, which are
often multileveled.
A Fictional Case
Study
To understand how each approach
can aid in a typical therapy let’s have a quick look at an
example. Suppose Client A (Let’s call him Ben – he is pure
fiction!), arrives with generalised anxiety. Upon further
investigation we learn that Ben also has an irrational fear of
balloons and spends a large part of every day working as a delivery
driver worried that a child may turn the corner carrying a balloon.
He also fears that one of the shops he delivers to may have inflated
balloons on their premises. CBT could take care of this difficulty,
but it would probably average at least three or four working
sessions of graded exposure tasks, alongside continued adjustment of
thinking and behaviour. With hypnotherapy, using NLP techniques, we
would expect to be able to quickly desensitise and re-frame this
difficulty in perhaps one or two sessions. We will usually create a
more thorough recovery with this type of difficulty using
hypnotherapy because an irrational fear of balloons is a
subconscious mind response that will respond beautifully to the
techniques hypnotherapists use to de-sensitise phobic templates.
Separately, Ben also worries that the people in the shops he
delivers to don’t like him, and is concerned that a customer might
make a complaint about him and that he’d lose his job. Using CBT
techniques we could have Ben record his thoughts each time he feels
this way, and in so doing, we could then have a look at the
situation and examine the evidence for and against this possibility.
With a rational objective evaluation we would discover that these
feelings and thoughts are not supported by any strong evidence but
are in fact part of the anxiety pattern created by Bens worry about
balloons. Using CBT we could teach Ben to remain calm and confident
enough to cease endorsing these feelings as a true threat and to
start behaving as though they are just negative automatic thoughts.
Through noting the evidence that people are busy doing their jobs
and respond to Ben just fine, and that Bens job is safe, we would
soon change Ben’s belief about himself being disliked at work, and
insecure in his job. Ben would gain confidence and being calmer (not
worrying) at work will reduce his anxiety generally. We can use
hypnotherapeutic mental rehearsal to have Ben imagine himself being
calm at work, and can create post-hypnotic suggestions that will be
activated when he arrives at the delivery which help Ben to maintain
his positive mood and walk with confidence etc. This new perspective
and understanding sends a message back to that core belief that Ben
does NOT endorse it. Over time then the core beliefs adjust rather
than Ben himself having to adjust (by remaining anxious) to the core
beliefs.
So, with this nicely black and
white example we can see why having access to both therapies helps
and how each therapy can reinforce the other. CBT gives structure.
Hypnotherapy quickly deals with subconscious mind resistance to
assuming new perspectives. This process is highly flexible and can
be used to address almost any emotional difficulty. What makes it
particularly powerful is that it is structured and logical, whilst
encouraging both subconscious and conscious mind adjustments,
essentially covering all the bases. When the conscious mind and the
subconscious mind are in agreement then there is no conflict and
change can be surprisingly easy.
About
me and CBT
I am primarily a
hypnotherapist. During my career as a hypnotherapist I have always
incorporated basic CBT understanding into my overall approach, so
CBT is not new to me. However, during January, February, and March
of 2008 I undertook further formal training in CBT to extend my
skills, earning my Diploma in Cognitive Behavioural Hypnotherapy.
This diploma is expected to be externally accredited to
national occupational standards by NCFE
to NVQ IV level. An update will be posted here as soon as this
qualification has been confirmed. CBT practitioners who offer CBT as
their primary therapeutic model undertake extensive training purely
in CBT, and are usually members of the associated CBT professional
associations. For this reason we make the distinction that I am a
Hypnotherapist with some formal CBT training rather than a CBT
Therapist. Nonetheless, as I hope I have explained, CBT and
hypnotherapy work beautifully together, and my formal CBT training
means that I have a solid working knowledge of the principles and
applications of CBT.
As a general rule, I will take
a hypno-therapeutic approach to most difficulties which incorporates
CBT principles/application where appropriate and helpful. This does
not however mean that we are limited to working this way. We can
place more emphasis on CBT or hypnotherapy according to your
preference. They are in fact two routes to the same place. I will
explain the benefits of each approach if necessary and we would find
a way that is best suited to you.
If you would like some help
with a difficulty, please do feel free to contact me for a free
consultation.
If you would
like to book a consultation with a view to starting treatment in
Bristol or Bath you can contact me, call on 0117 904 4504 or email
me.
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