What is CBT? Cognitive Behavioral Therapy is a mental health psychological treatment, or psychotherapy. The range of problems it treats is broad, from anxiety and depression to substance abuse and relationship problems. It is considered gold standard treatment (especially for OCD, Social Anxiety, and more). It is also seen as a first line treatment for a range of problems and goals. I’m here to help you nerd-out and understand a bit more about where it comes from and ideas on how it works.
Cognitive Behavioral Therapy in 3 Parts
CBT is often conceptualized on a triangle, such as the following “ABC”:
This triangle reflects no particular order or prioritization.
Every psychotherapy’s core question- and the role of theory.
By and large, it can be argued that any major system of psychotherapy at its heart is asking the question, “How does change occur in people? OR What effects change?” Change can be a quite comprehensive term, and may involve modification of feelings, distress, pain, suffering, hope, and much, much more.
Many people don't know that any medical treatment is born out of theory and still operates in the realm of various theories as to how and why they work. It is argued that the brain is the most complex object in the known universe, so staying “open-minded” (my attempt at a pun) and patient with learning is warranted. Even the assumption that mental health is brain health is based on, well, theory. And it may turn out to be overly reductionist from a research standpoint.
“All thinking involves theories….” (Alderson, 1998).
Most all my readers have experience with a traditional family doctor. They likely practice from what’s known as “the medical model,” which is a theoretical approach. Some may confuse this as only “symptom/problem focused,” but it is more pattern recognition (Aftab, 2020).
CBT is based out of both behavioral, social, and cognitive learning theories (Davis et al., 2017):
When did CBT first come into use?
As with most things that involve credit giving and fame, the début of most theories can be likened to an academic bare-knuckle brawl which lends to the asserting of various individuals and institutions as the rightful heir to said throne. Yes, the key names in its development were certainly Albert Ellis and Aaron Beck, but just as multiple theories converged to birth CBT, so did multiple researchers, voices, and systems. By and large, cognitive theory began disrupting the dominant behavioral theories in the 1960’s and 70’s, gaining steam in the therapeutic community by late 70’s and 80’s.
Ride the wave.
CBT is often seen in “three waves (Hayes and Hofmann, 2017).”
What does it treat?
Treatment for Anxiety, Depression, and OCD are common with CBT. You can find the robust treatment of PTSD, substance abuse, relationship problems, eating disorders, Bipolar Disorder, psychosis, chronic pain, general health, and much more, as well.
Any successful treatment has its limits, and Cognitive Behavioral is no different. Autism by and large is treated through Behavioral Therapy (specifically ABA). Those looking for supportive psychotherapy (talk therapy) to verbally process may prefer someone who spend more time working with this approach (though many CBT clinicians are quite good when warranted). Personality disorders are thought to be better treated holistically by DBT, which, though originally based out of CBT, is distinct in some regards. Furthermore, those lacking insight or awareness may not respond well to the requirements of CBT that involves self-monitoring and actively engaging in various changes based on the individual’s awareness and willingness.
Hallmarks of CBT.
Personalized hallmarks of CBT.
While CBT is largely characterized by the above, variations exist additionally, such as in my practice, where appropriate:
CBT and you.
Though there are many effective therapy treatments to date for a range of issues, CBT comes out as the most researched, most helpful for the widest range of problems, and can be highly personalized. If you are considering (or reconsidering) CBT, it is crucial to advocate for yourself and ask good questions of a potential counseling provider, typically in a first session:
For Further Reading:
What is CBT? (APA)
Cognitive Behavioral Therapy (IQWiG/informedhealth.org)
Evolution of CBT (NIH)
History of CBT in Youth (NIH)
The Importance of Theories in Health Care (NIH)
The Origins of Cognitive Behavioral Therapy (PsychCentral)
“ERP (Exposure and Response Prevention) is not working.” “I’ve tried ERP before- it doesn’t work for me.” I have many current and past clients who said this once. You might think, given my practice focus, that I would simply respond by offering more ERP. Not necessarily. Let me say what I don’t do, first. I don’t automatically say, "MORE ERP!" What I do is dig deep in assessment, first. Your outcomes are highly connected to whether you have done a few crucial things in your Exposure and Response Prevention for OCD. Here are common reasons you aren’t getting the most benefit you could.
#1: You haven’t given ERP a real chance.
Let’s just start with the obvious- you can’t get the benefit of a treatment if you haven't tried it. Have you tried another approach instead that is NOT ERP?
Please note that at any given point, all of the approaches listed above (EMDR, talk therapy, etc.) can be useful for a variety of things; they are just not the clinical first option for OCD!!!
Hear me loud and clear, because it needs to be said: if you're serious about getting better and have access to it- go for the gold standard Exposure and Response Prevention. The rationale and research is extensive- you can find it in my ERP for OCD presentation and ERP for OCD Brochure.
#2: You tried and “failed.” You might need to increase the quality of your ERP or attempt another trial.
If we sit down in assessment, and you say anything like the following, the quality of ERP may have been lacking, and we need to “up your game.”
Use this handy checklist ✅:
Though this is a very thorough list, it’s not even cumulative. There are even more! All of this to say, ERP is a very deep and powerful tool. Don’t give up too soon.
#3: You gave up without considering many viable OTHER treatments.
Now that we’ve covered many reasons that ERP quality may have been lacking, there are certainly those who receive solid treatment from a trained clinician, but they still are having problems. It happens in my practice; it happens with the world’s foremost experts, too. OCD is a formidable foe, and we are complex as human beings- no one size fits all. OTHER OPTIONS EXIST!!! As you consider with your clinician what’s not working, consider the following:
#4: Though it's uncommon, you may have tried many options above. Keep pressing on.
This is part of the uncertainty we have to accept- and work towards. A generation ago the tools we have today didn't exist as they do (ERP got full steam in the 80’s and wasn’t available in your average practice until later)!!! OCD, especially severe cases, was seen as largely difficult to treat or untreatable by many providers for most of the 20th century.
I have seen personally- and the experts attest- there is usually hope for those who keep pressing on, even in the most severe of cases. Check out Dr. Liz McIngvale’s personal story to to be encouraged.
So if you have doubts and fears about ERP, have tried it and it hasn’t worked for you- or have avoided it, I have good news- there likely exists options for you. And even those who seem to run out of options can typically find many if they keep persevering. You are valuable and significant, no matter how you feel today. I hope to be an encouragement in your journey.
A Psychotherapists' thoughts on healthy living.
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