Monthly Archives: January 2013

Explaining Cognitive-Behavioral Therapy

Much has been written on the merits and principles of cognitive-behavioral therapy (or CBT).  As I have stated in a previous post, I utilize CBT as a primary style of doing therapy.

For most of my clients, one of my first interventions (a fancy term for essentially anything a therapist does in a session) is to explain the theoretical model.  Part of the rationale for this is what therapists call transparency, which is essentially the idea that clients should be informed about what the therapist is doing and why.

CBT has a relatively shorter history than other therapy models, and there are a number of branches and specialties stemming from the crux of the ideas.  What I discuss here is how I choose to explain the concept to clients.

At the center of CBT the basic premise that, within each person, there is an interaction among their thoughts, feelings, and behaviors.  These are in turn affected by a person’s biological responses and the situation in which a person finds herself.

I often draw the concept in this way: cbt

Typically, as I draw, I explain some examples of how this works, using the experiences and symptoms of my client.

One example I use frequently is this:

Let’s begin with a situation.  Let’s say that you are driving in traffic and someone cuts in front of you dangerously.  Most people will say that they feel angry and scared when that happens. Well, how do we know that we’re angry and scared?  Usually, our heart beats faster, our palms get sweaty, our muscles tense, our chest can feel tight, and we have this feeling like we want to move.  That’s the biology that’s happening.  Our thoughts often go something like this: ‘What a jerk!,” “I almost died!,” and things of that nature.  Then, we’ve got our behaviors; these vary widely person to person, and can include vulgar language shouted at the windshield, rude hand gestures, or smacking of the steering wheel.

Of course, some people don’t react this way, and are able to be calm, even in dangerous and frustrating situations.  Generally, though, the principle stands. When we are in a situation, our body and mind react quickly, often in ways we never think to control; much of this happens immediately and automatically.  When people seek treatment, often there is a pattern of these reactions that are unhelpful or disruptive to their lives.  CBT focuses on interrupting the feedback loop by working to change a client’s thoughts and behaviors to ones more congruent with their goals.

The way that is achieved varies greatly from person to person, and CBT therapists have developed a slew of interventions, worksheets, and scripts to address these concerns.

Overall, one thing that makes CBT different from, say, psychoanalysis, is that CBT therapists do a lot of teaching, use handouts, complete worksheets, assign homework, and generally take a more active and concrete role in the therapy.  The focus is on action and change; something that many clients find helpful and empowering (although certainly not all).

In the end, however, my job is to give my clients the best treatment possible, and if, for that person, CBT is a poor fit, I use the training that I have in various other methods to provide my clients with what they need.

What is Psychotherapy, Anyway?

One of the most pervasive publicly-held ideas about psychotherapy is that it consists of the therapist simply listening to her client complain.  Everyone has seen the image of psychotherapy like this one:

toon283“All I want to do is lie around all day. This isn’t helping.”

In reality, none of the therapists I know work in this manner.  Instead, this modality is more consistent with a therapeutic style known as psychoanalysis, which is typically focuses on a client’s past, involves more frequent visits, and is commonly associated with Sigmund Freud.  This is what was developed at the psychotherapy’s beginnings; since then, a lot of research has been conducted, and many other styles of therapy have been created and tested.

Each therapist chooses his or her own style of treatment, including what is called their “theoretical orientation,” which basically means the way in which the therapist views her clients her beliefs about why people develop certain symptoms, and the best way to treat them.  Some that may seem familiar: psychodynamic, cognitive-behavioral, family systems, dialectical behavioral, and humanistic therapies.  Each has their own explanation of clinical psychological disorders, and each has their advantages and disadvantages.

There is also an entire body of research supporting the idea that a therapists’ theoretical orientation does not matter per se, as long as they provide their client with certain basic things – called “common factors theory” – their client will improve.  These common factors include things like warmth, empathy, and trust.

Most therapists I know do not ascribe to or use only a single theory.  Most, myself included, would describe themselves as using more than one, depending on the client. On the other hand, I also have very distinct leanings towards cognitive-behavioral therapy (or, CBT).

Part of the reason for this is my own personality; I am a person who likes structure and who enjoys color-coding, making spreadsheets, creating schedules, and following a specific plan.  Another reason why I like CBT is because, among many of the most popular orientations, CBT has a remarkably strong body of research supporting its results.

A part of this is assuredly because, by it’s nature, it is structured and therefore more easily lends itself to scientific inquiry (as compared to psychoanalysis, where there is no step-by-step procedure).  And, to be sure, many factors affect what gets studied and what does not.

All the same, to me, the science speaks loudly and I consider that part of my job is maintaining an awareness of the most current research in my field.  I believe that doing the best by my clients means using the information available paired with my own judgment and instincts.  For me, CBT is comfortable and effective.  And when I am most comfortable, I am most effective in helping my clients achieve their best results.

Still, it’s not right for everyone, and that’s why I don’t use it with rigidity; I use interventions from other theories and I listen to what my clients are telling me they need – even if they never use those words.

Ultimately, my job is to do the best for every client and that means tailoring treatment to the unique needs and preferences of each person, couple, group, or family with whom I work.  So I use the science available as much as possible, all the while knowing that said research is imperfect and that the human mind and relationships remain more complex than modern science can address.

On Being a Therapist

When I introduce myself to people for the first time and I tell them that I am a therapist, one of the first things I am usually asked is: “how can you stand listening to people whine about their problems all day?”  At first, I would give a lot of half-baked replies about the parts that I like about being a therapist.  Eventually, I realized, however, that what people were really asking is: “it is painful for you? and does my own therapist resent me?”

My answer: I love what I do, and I would not trade it for anything.
Yes, it is true that my job entails dealing with, talking about the most difficult and painful parts of people’s lives; more than that, though, it is about helping people improve their lives.  Clients do not come into therapy to complain, they come in to work; they want to make their lives happier and healthier, and my job is to help them achieve that goal.

Just like physicians are faced with disease every day, which is an unpleasant thing in of itself, so are psychotherapists faced with psychological and emotional difficulties.  And, like physicians, the focus of the work is essentially on the solution rather than on the problem.  Disease is not enjoyable, but finding and seeing the results of the right treatment is incredible.

At least, from my perspective as a therapist, that is what the focus should be.
With that, the difficulty of hearing about sadness, worry, and anger throughout my work day is far overshadowed by the joy of seeing people achieve their goals and change what is ailing them when they first come into my office.

Being a therapist is an amazing thing, and an incredible privilege.