Whether you are in training or an experienced practitioner, you need more than a rudimentary understanding of cognitive-behavioral therapy (CBT). This easy-to-use psychotherapy has broad empiric support, is a first-choice treatment,1 and can help patients cope with depression, anxiety, and other psychological problems.
Psychiatrists who learn CBT well can alleviate many patients’ distress by creatively applying its tools and techniques. For example, the cognitive approach to panic disorder compares favorably to medication1-3 (Box).
Aaron beck’s CBT
Negative thoughts, biased processing. The greater your fidelity to CBT’s guiding principles (Table 1), the more effective the therapy becomes.4 Beck designed CBT to address his observation that depressed persons hold unrealistically negative views about themselves, the world, and the future.5,6 A distorted information-processing system prevents them from correcting underlying negative beliefs. Negative thoughts predominate their cognitions and seem to arise spontaneously, reflexively, and unremittingly. These “automatic thoughts,” as he called them, reflect underlying themes about the self that can be identified as:
- intermediate beliefs (conditional assumptions, attitudes, and rules)
- core beliefs (fundamental, often global, and absolute rules).7
Treating anxiety disorders with CBT: A first-line therapy
Table 1using CBT to experientially disconfirm catastrophic cognitions is the psychotherapy of choice for anxiety disorders.1 Cognitive models exist for each anxiety disorder2 and include psychoeducation, self-monitoring, evaluation of anxious cognitions, and testing cognitions interoceptively (within the body) and in vivo (within the environment). The therapist strategically uses adjunctive measures such as relaxation training, controlled breathing, visualization, and distraction.
Panic disorder is characterized by catastrophic misinterpretations of benign bodily sensations that accompany a fear response.2,3 Disability occurs when patients avoid situations or activities they believe will activate bodily sensations such as dizziness or breathlessness. Using environmental manipulations—spinning, hyperventilation, or straw-breathing, to name a few—CBT aims to disconfirm patients’ catastrophic thoughts by deliberately exposing them to feared somatic sensations.2
When used to treat panic disorder, CBT is associated with remission rates similar to those achieved by medication and much lower relapse rates.1
Guiding principles of cognitive-behavioral therapy
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- external (environmental) stress that carries symbolic value
- internal (physiologic) stress that activates the affective valence of the underlying schema.1,5,6
CBT’s scientific method. CBT teaches a person the skills to identify this cognitive material and to recognize biases that affect how he or she processes information. You can help patients understand:
- the bidirectional relationship between thoughts, feelings, and behaviors
- that they can influence their emotions by changing their thoughts and behavior.
You provide empiric tools to help them explore the validity or usefulness of their thoughts and the impact of their behaviors. When patients disprove a negative cognition through this process of “experiential disconfirmation,” you help them to change that cognition. Homework is a key ingredient (Table 2); patients who do their CBT homework are more likely to improve than those who don’t.8
Table 2
Structure of a typical CBT session
| Step | What therapist may say or do to introduce this step |
|---|---|
| Collaborate in setting the agenda | ‘What would you like to put on the agenda for today’s session? If we could address one or two items, what would they be?’ |
| Link to previous session via feedback | Review and comment on the patient’s feedback form |
| Check target symptoms | ‘How would you rate your level of (depression, anxiety, etc.) this week on a scale of 0 to 100?’ |
| Therapist also can review standardized rating scales, such as Beck Depression Inventory II | |
| Check medication | ‘Are there any concerns this week about your medication?’ |
| Review week/scheduling | ‘Could you update me about your week?’ |
| ‘What would be important to focus on this coming week?’ | |
| Review homework | ‘Let’s have a look at the homework/self-help work you did this week’ |
| Set new agenda items | ‘This issue sounds important; would you like to add it to today’s agenda?’ |
| Collaborate in developing new homework | ‘I’d like to work on this further next week; let’s decide together what would be doable’ |
| Feedback | ‘How did you feel about today’s session?’ |
| ‘Is there anything you would like to be sure to remember after you leave today?’ | |
| ‘Anything you want to put on the agenda for next session?’ |