Psychotherapy represents a collaborative intervention between one or more clients and a therapist.
Therapy is designed to provide information, ideas, and techniques to help individuals improve their lives and change certain aspects about themselves. Clients may be interested in changing certain behaviors or attitudes, dealing with stress, improving relationships, improving skillsets, etc.
In order for an intervention to be formally defined as a form of psychotherapy, it must be administered by a trained therapist who has an understanding of psychological principles and applies these principles during the sessions. Trained therapists are most often psychologists, social workers, or counselors. These individuals have specific postgraduate training and experience, and they are required to pass a formal examination in order to be licensed in their state. Other types of interventions that do not utilize a trained therapist and/or the use of psychological principles are not formal forms of psychotherapy. This would include the majority of social support groups (usually run by peers), a number of different adjunctive types of therapies (e.g., yoga therapy, art therapy, etc.), and other interventions, such as occupational therapy or speech therapy.
According to the American Psychological Association, there are literally hundreds of different types of psychotherapy. The majority of these different types of psychotherapy have originated from one of five major schools of thought that have been prominent in the field of psychology for quite some time. The most utilized form of psychotherapy is Cognitive Behavioral Therapy, a form of psychotherapy that originated as a result of combining two of the five major paradigms in psychology, cognitive psychology, and behavioral psychology.
What Is Cognitive Behavioral Therapy?
Psychotherapy as a structured discipline is often traced back to Sigmund Freud regarding its formal origin; however, different types of talking approaches to helping individuals have been in existence for centuries. Freud’s form of psychotherapy was quite different than many other approaches that were used in his time. Freud attempted to understand the unconscious conflicts deep within the mind of an individual to explain and treat certain types of psychological problems. Freud’s techniques were indirect, long, and very complicated.
Freud developed numerous theories regarding the structure of the mind, the development of personality, and how different types of major psychological disorders develop. While many of his assumptions are now considered to be antiquated, Freud did make numerous contributions to psychotherapy that are still considered to be relevant today. One of these major contributions was the notion that people often do not understand what drives their behavior, and many times, the explanation of why an individual acts in a certain manner is extremely complicated and dependent on situation-specific issues.Freud believed that all psychopathology resulted from early childhood experiences. While the belief that childhood trauma can result in dysfunctional adult behaviors is still relevant today, it is understood that not every dysfunctional behavior has its origin in stress or trauma experienced in childhood. Freud also believed that individuals develop dysfunctional or psychopathological behaviors as a means to cope with dysfunctional sources of anxiety. This finding is also still relevant today, and the investigation into how individuals perceive their world fueled the school of cognitive psychology.
Cognitive psychology developed as a reaction to both Freudian thought and the behavioral school of psychology that ignored thoughts, feelings, and emotions, and instead concentrated on environmental stimuli as the major means of explaining behavior and learning. Using the same types of experimental methodologies used by the behaviorists, early cognitive psychologists were able to show that even rodents were able to make cognitive maps of their environment to allow them to return to places where valuable resources, such as food and water, were. Behaviorists had emphatically stated that all learning was due to reinforcement or punishment, and they had often discredited the notion that cognitive structures could influence behavior.
Both cognitive psychology and behavioral psychology were initially the domains of experimental psychology where the major goal is to form research models, develop theories, and explain certain types of behavior or experience. However, behavioral psychologists were able to apply numerous behavioral principles to psychotherapeutic situations and create techniques to help individuals in therapy deal with anxiety, depression, and other unwanted feelings.
As psychotherapists in America became more disillusioned with the Freudian model of therapy, attempts to combine the theoretical concepts of cognitive psychology and behavioral psychology resulted in the development of Cognitive Behavioral Therapy.
Most historians credit the therapist Dr. Albert Ellis as developing the first form of Cognitive Behavioral Therapy with his Rational Emotive Behavior Therapy.
Cognitive Behavioral Therapy Represents a Family of Psychotherapies
Cognitive Behavioral Therapy (CBT) is not one specific type of therapy; instead, it is composed of numerous types of therapies that are based on several basic principles. There is no one type of CBT. There are basic principles that drive all forms of CBT.
The central idea that drives all forms of CBT is that individuals who develop inflexible and irrational beliefs often act in ways that result in significant distress or dysfunction. The types of inflexible and irrational belief systems that CBT therapists are concerned about include:
- Irrational and dysfunctional beliefs about oneself and how one should be
- Irrational and dysfunctional beliefs about other people and how they should react
- Irrational and dysfunctional beliefs about the nature of reality
- Most often, individuals develop these inflexible and irrational belief systems as a result of early upbringing or early experiences; however, it is not necessary to visit remembrances of childhood in order to treat these issues in the manner that psychodynamic therapists like Sigmund Freud did.
- The goal of the therapy is to assess the individual and listen to them in order to identify particular themes in their thinking that represent one or more of the three major types of irrational beliefs. The therapist then challenges these beliefs, demonstrates how they are irrational and dysfunctional, and helps the client to change them.
- As a result of altering their rigid and irrational beliefs, individuals also alter their behavior. Therapists use a combination of both cognitive techniques and behavioral techniques to help them change.
Because many of the core dysfunctional underlying schemas, or models of the world, that individuals with psychological problems develop are ingrained within their habits and other cognitive structures, it is extremely important that individuals who practice CBT have intensive training and experience in recognizing how these types of belief systems manifest in reality and how to approach them. It is not just a simple matter of telling someone that their belief is wrong and then telling them how to change their belief system.
The approach of Cognitive Behavioral Therapy is very intense, relies on a collaborative effort between the client and therapist, and consists of significant analysis, experimentation, and trial-and-error approaches to finding out how to solve the issue.
The overall approach used by most CBT therapists, despite the specific type of CBT used, is outlined below.
- The therapist initially performs an assessment or functional analysis of the client’s problematic behaviors. The functional analysis is a behavioral technique that helps the therapist to identify specific problematic behaviors that need further investigation. In addition to the functional analysis, the CBT therapist also learns as much as possible about the client’s history, current living situation, goals, thoughts, expectations, etc. The therapist also aims to achieve a detailed understanding of the issues that brought the client to therapy. Therapists typically use the first several sessions to assess the client’s situation and continue to assess the person throughout the course of therapy.
- Once the initial portion of the assessment is complete, the therapist will attempt to identify the major issues, such as dysfunctional patterns of thought, dysfunctional behaviors, etc., that are associated with the reasons that brought the client to therapy. Therapists typically develop numerous hypotheses regarding the issues that are troubling the client.
- As the therapy continues, the therapist helps the client to recognize rigid, irrational, and dysfunctional beliefs, attitudes, expectations, or other thought patterns that contribute to their presenting problem. The therapist and client discuss the therapist’s hypotheses; the client tests them out in the real world; and then, they both reevaluate their findings. Through this process, the therapist helps the client to recognize the issues that drive their problematic behaviors.
- As the core themes that result in dysfunctional feelings and behavior are identified, the therapist then begins to use specific types of cognitive restructuring techniques to help the client develop a more realistic and functional viewpoint.
- During the entire process, the therapist and client continue to practice and discuss issues in therapy. The therapist gives the client homework to test hypotheses and viewpoints outside of the therapeutic session. They continue to collaborate and discuss the results of their work.
- As time goes on, the client begins to become more adept at understanding their issues, recognizing problematic beliefs and patterns of thought, restructuring these, and changing their behavior. The goal of the therapist is to help the client become autonomous.
- CBT adopts a time-limited approach, such that once the issues that brought the client in the therapy have been addressed, the therapy is terminated. Many times, therapists begin to discuss termination with the client several sessions before the actual termination date. This allows the therapist and client time to review progress, address any areas that need to be addressed, and ensure that goals of the therapy have been met.
- Often, after the therapy is terminated, clients may return for “booster sessions” or to address new issues. High-quality CBT therapists follow up with their clients.
As mentioned above, Cognitive Behavioral Therapy describes an overall approach to therapy, but it is not one particular type of therapy. There are numerous types of CBT that all operate on the same general principles, but they are utilized for specific types of issues or have specific types of approaches based on CBT principles. Some of these types are outlined below.
- Rational Emotive Behavior Therapy: As mentioned above, Rational Emotive Behavior Therapy (REBT), developed by Dr. Albert Ellis, is often acknowledged as the first type of CBT. REBT outlined the general approach used by all forms of CBT, such that Ellis believed that many dysfunctional behaviors and forms of psychopathology had their origins in inflexible and dysfunctional patterns of beliefs. His goal was to identify these beliefs, challenge them, help the client to change them, and then help the client to change their behavior. REBT continues to be a very popular form of Cognitive Behavioral Therapy, and it has extensive research to support its use in numerous contexts.
- Dialectic Behavior Therapy: Dialectic Behavior Therapy (CBT) is a form of CBT that was developed to specifically address issues with severe emotional distress, such as what occurs in suicidal individuals. It has become the frontline treatment for severe issues, such as borderline personality disorder.
- Motivational Interviewing: The Motivational Interviewing technique was developed according to CBT principles to identify where people who had substance abuse problems stood regarding their awareness of their behavior being problematic or dysfunctional and their willingness to attempt to change their behavior. The model developed a transtheoretical stages of change model that attempted to identify different stages where individuals with certain types of problematic behaviors are regarding their awareness of their need to change and how to go about changing their behavior. The Motivational Interviewing technique focuses on CBT principles to get individuals, such as those with significant substance abuse problems, who are resistant to change to realize the need to change their behavior.
- Other forms of CBT: Different types of CBT techniques are utilized for different types of mental health disorders. For example, there are special CBT approaches to treating individuals with panic disorder, depression, trauma- and stressor-related disorders, phobias, and other mental health disorders. While the different therapies utilize different techniques, they are all based on the general principles of CBT.
Cognitive Behavioral Therapy is the most researched form of psychotherapy. Different types of CBT have numerous research studies documenting their effectiveness for treating various issues, including anxiety, depression, eating disorders, personality disorders, trauma- and stressor-related disorders, and substance use disorders. Various professional texts often state that CBT is the preferred form of treatment for several different types of psychiatric disorders, including panic disorder, phobias, trauma- and stressor-related disorders, and substance use disorders. Even though medications can address some of the symptoms in these disorders, medication cannot help individuals change their behavior and develop long-term coping strategies.
There are conditions in which CBT techniques are not indicated, such as for individuals who are actively psychotic, who have severe cognitive problems, or for the direct treatment of certain types of disorders, such as bipolar disorder. CBT techniques can be used to help individuals with psychotic disorders and bipolar disorders with medication management and adjustment, but only when they are stable as a result of medical treatment.
In addition, the effectiveness of CBT lies in the working relationship between the therapist and client. Clients must actively be part of the therapeutic process as opposed to passively taking advice from the therapist. This includes participating during therapeutic sessions as well as actively completing homework assignments that are assigned during therapy.
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