The Cognitive Behavioral Psychotherapy (CBT) is a psychotherapy developed in the 60s by AT Beck (pictured) and adopted today in clinical practice for most of the psychotherapists in Europe and worldwide. It is, in fact, the therapy that boasts the greatest scientific confirmation on the national and international scene. It is a structured therapy (it is structured according to a well-defined structure, albeit not in a rigid way, to ensure maximum effectiveness), directive (the therapist instructs the client and actively assumes the role of “expert counselor”), of short duration (changes significant are expected within the first six months) and present-oriented (aimed at solving current problems, although generally the origin dates back to childhood).
It is aimed at modifying distorted thoughts and beliefs, dysfunctional emotions and maladaptive behaviors, producing the reduction and elimination of the symptom and making lasting improvements over time.
The Cognitive Behavioral Therapy is a therapy suitable for the individual treatment, torque and group, and it works regardless of the cultural level, social status and sexual orientation. It is empirically validated with both adults and children and adolescents.
How Beck’s cognitive model is born
In the early 1960s, Aaron T. Beck was a researcher in psychiatry at the University of Pennsylvania. Beck was a psychoanalyst already trained but with a scientific nature, in fact he thought that in order for psychoanalysis to be accepted by the scientific community it was necessary to demonstrate its empirical validity and for this he decided to do research on depression. Beck wanted to test the psychoanalytic concept that depression is the result of self-directed hostility.
He studied the dreams of depressed patients, who he hypothesized would exhibit more hostility themes than those who did not suffer from depression. To your surprise, Beckhe found that the dreams of depressed patients contained fewer themes of hostility and many more themes of defects, deprivation and loss and that these were, instead, parallel to the way of thinking patients had when they were awake. Listening to the patients, Beck quickly realized that they occasionally reported two streams of thought, one with no associations and another made up of quick thoughts, which usually contained self-evaluations. Beck called these latter automatic thoughts. It was evident that this second stream was closely related to their emotions and then it began to help patients identify, evaluate and respond to their unrealistic and maladaptive thinking and these improved rapidly. Beck thus began to develop structured, short-term psychotherapy
”(…) Man holds the key to understanding his psychological disorder within the field of his consciousness. He can correct the wrong conceptions that produce the
emotional disturbance , with the same method used to solve problems during the various stages of his development ”. (Beck, 1976).
What is the theoretical model behind cognitive-behavioral therapy
In addition to the classical references of behaviorism, Cognitive Behavioral Therapy is based on the cognitive model, which assumes that people’s emotions and behaviors are influenced by their perception of events. It is not the situation itself that directly determines what people feel, but rather how they interpret it. At the origin of the disorders there is, therefore, a distorted way of thinking, which negatively affects mood and behavior. The Cognitive Behavioral Therapyhelps people identify their dysfunctional thoughts, such as distressing ones, and evaluate how realistic they are. By highlighting misinterpretations and proposing alternatives – that is, more plausible explanations of events – an almost immediate decrease in symptoms is produced. Indeed, a realistic assessment of situations and a change in thinking produce a corresponding improvement in mood and behavior . But to achieve a long-term outcome, it is necessary to modify the underlying dysfunctional beliefs by training clients in these cognitive skills.
The interactions of the subjects with the world and with other people lead them to develop certain beliefs through learning – their beliefs – which can vary in accuracy and functionality. Through Cognitive Behavioral Therapy, dysfunctional beliefs can be “unlearned” and new, more realistic and functional beliefs can be learned and developed. In summary, Cognitive Behavioral Therapy will act on automatic thoughts (which are the most superficial cognitive level: the distorted thoughts and images that quickly and uncontrollably cross the mind of a person in front of certain specific situations and negatively condition their mood), the intermediate beliefs(opinions, rules and dysfunctional assumptions) and core beliefs (which constitute the deepest level: they are global, rigid and hypergeneralized and are learned in childhood and adolescence) The cognitive behavioral therapy involves the use of technical specifications, different for each disorder, behavioral and cognitive matrix, peculiar to each of the three levels of the above thought.
The following figure illustrates the interaction of the three cognitive levels.
10 Basic principles of Cognitive Behavioral Therapy
- The Cognitive Therapy C omportamentaleis based on an ever-evolving formulation of the problems and a conceptualization of these in cognitive terms.
That is, it starts from the current way of thinking and from the behavior of the person and then goes back to the triggering factors and key models, learned in childhood, for interpreting reality. Identify the automatic thoughts, intermediate beliefs (values, rules and assumptions) and the basic, deeper beliefs that led to the onset and maintenance of the problem; - the Cognitive Behavioral Therapyrequires a solid therapeutic alliance.
The creation of a relationship based on warmth, empathy, care, sincere respect and competence is fundamental; - The Cognitive Behavioral Therapyemphasizes collaboration and active participation.
Encourage to see therapy as a team effort: together patient and therapist decide what to work on. Make the patient become more and more active in the sessions; - the Cognitive Behavioral Therapyis goal-oriented and focused on the problem.
Goals are set together with the patient, trying from time to time to assess what hinders their achievement; - The Cognitive Behavioral Therapyinitially focuses on the present.
It starts from current problems and specific painful situations, from the here and now, to then shift the attention towards the past in order to find and understand the childhood roots that are the basis of their beliefs (rigid and absolute ideas about themselves, others and how the world goes); - in Cognitive Behavioral Therapyaims to teach the patient to be the therapist himself and focuses on relapse prevention.
- The Cognitive Behavioral Therapyis intended to be limited in time.
Providing symptom relief, facilitating remission of the disorder, helping patients with their problems and teaching relapse prevention skills to be used for the rest of their lives over a defined period of time. Not all patients make progress in a few months, in some cases longer treatments will be needed; - the Cognitive Behavioral Therapyis characterized by structured sessions.
The structure includes an introductory part, an intermediate part where we discuss the topics on the agenda and where we work together on the homework done during the week and a final part where we always ask for feedback from the patient. Following this format makes the therapy process more understandable to the patient; - The Cognitive behavioral therapyteaches patients to identify, assess and respond to their thoughts and their dysfunctional beliefs.
That is, to identify key dysfunctional cognitions and adopt more realistic and adaptive perspectives. This will lead to feeling better emotionally and behaving in a more functional way; - The Cognitive Behavioral Therapyuses a variety of techniques to change the way of thinking, mood and behavior.
The choice of techniques to be used will be influenced by the patient’s conceptualization (re-reading of the problem in a cognitive key), by the types of problems reported and by the objectives of each individual session.
An example of Cognitive Behavioral Therapy
Marco is a young employee, recently hired in a large company. He is very scrupulous, so much so that he works late every night in the office to do his job perfectly. Finally his girlfriend convinces him to take a day off and spend the weekend out of town. On Friday afternoon, while on the road, he gets a call from the office. “ There must be something wrong, I must have made a mistake ”, Marco thinks.
To call is a colleague who is looking for a file. Unfortunately, the cell phone battery is almost empty and Marco is unable to complete the conversation. He immediately begins to feel agitated. “Where can I have put the file? Why can’t they find it? I definitely put it in the wrong folder. What if I accidentally deleted it? I’m too careless. I will never be a good employee ”.
Marco begins to worry about what they are saying about him in the office. ” They will think that I am an imprecise employee, that I cannot be trusted “. The heart begins to beat faster and faster, while it continues in vain to try to phone. Then he begins to accuse his girlfriend of making him make a mistake by leaving. ” I will probably be fired or in any case I will never make a career, because I immediately revealed my incompetence, and it is also your fault that you always accuse me of working too much .” Marco and his girlfriend fight and on Saturday they go back to town.
Marco is increasingly agitated. He doesn’t have his colleague’s private number and has to wait until Monday to find out what happened. He spends Sunday imagining his boss’s reproaches and thinking about the best way to apologize for his mistake. On Sunday night he cannot sleep due to tension. It’s his first major job: he shouldn’t have made such a big mistake.
On Mondays he goes to the office, after having slept only a few hours and finds that his colleague had found the file a few minutes after the phone call in the folder where it should have been. He called because he didn’t remember which was the right folder. No one in the office was aware of this incident. Marco is relieved: no one has noticed anything. However, he is quite stressed and still thinks that he will have to be more careful and double-check everything several times.
In this example, the automatic thoughts that assail Marco and his basic belief: ” I am inadequate ” are evident . This deeply rooted belief leads him to experience negative emotions, experience profound discomfort, and engage in maladaptive behaviors. It also compromises his social and emotional relationships. Cognitive-behavioral therapy can help him see things more realistically, improve his self-esteem and develop an affirmative personality style.
For which disorders is Cognitive Behavioral Therapy indicated
Numerous studies have shown that Cognitive Behavioral Therapy is effective in treating a wide range of psychological disorders:
- the Depression
- anxiety and panic attacks
- obsessive-compulsive disorder
- phobias
- eating disorders (anorexia, bulimia, psychogenic obesity)
- forms of post-traumatic stress (emotional and physical / sexual trauma)
- sleep disorders
- alcohol, drug, emotional, sexual and internet addiction disorders
- sexual dysfunctions
- relationship problems
- personality disorders
- bipolar disorder and schizophrenia (combined with appropriate medication)
Duration of Cognitive Behavioral Therapy
Some people stay in therapy for a very short time, as little as six to eight sessions. In other cases, therapy may last a few months or, in sporadic cases, more than a year. This depends on the severity of the problem and the client’s motivation.
What exercises and how does the therapeutic process develop?
The first sessions are dedicated to knowing the client’s problems and building the therapeutic relationship.
The anamnesis phase (cognitive and behavioral assessment) is conducted using, in addition to the clinical interview, psychodiagnostic tests and is aimed at assessing the emotional state, reconstructing the salient experiences of his life and at a clear definition of his current problems and objectives.
When the case and the clinical diagnosis are defined, the therapist will explain the theoretical principles and aims of the therapy , briefly illustrate the techniques that will be used, as well as the timing, costs and probability of success of the therapy, as far as possible.
Subsequently he proposes to the client a therapeutic contract , in which he will summarize his evaluations, will present his hypotheses to the client, will formulate interpretations of the events and will share the cognitive and behavioral conceptualization of the case.
He will outline a therapeutic project , with concrete, useful and achievable strategies and objectives, connected with the problems explained by the client and consistent with his expectations.
We will then proceed with the actual therapeutic intervention , in a climate of trust and positive orientation towards change. Towards the end of the therapy, when the person feels better, the frequency of the sessions may be reduced over time until the end. Follow-up sessions may then follow three, six and twelve months after the end of therapy.
How the therapeutic sessions take place and how Cognitive Behavioral Therapy works
Usually, the sessions take place inside a study with armchairs and a small table or desk. The therapist and client are seated face to face, but their position may eventually vary if certain techniques are used (relaxation, role-playing, modeling, EMDR, MBSR, etc.). The sessions last about an hour, and their frequency is weekly (more rarely, twice a week). The atmosphere is relaxed, empathetic and collaborative. In addition to the interview, some therapeutic materials are often used in sessions, such as psychodiagnostic tests and questionnaires, daily diaries for recording and monitoring the client’s activities, cards for exercises in the studio and for homework. The homeworks are customized for each patient to be both useful and pleasant at the same time and can be commented on during the session or via e-mail. In addition, the Beck Institute provides patients with psycho-education and bibliotherapy materials specific to each disorder. After a quick check of the patient’s mood, an agenda is set, establishing the topics to be discussed in the session. In a collaborative way, the problems will be addressed with the most appropriate techniques. Then we will move on to the assignment of some homework, or exercises that the client will do during the week and which will be discussed together in the next session. After a quick check of the patient’s mood, an agenda is set, establishing the topics to be discussed in the session. In a collaborative way, the problems will be addressed with the most appropriate techniques. Then we will move on to the assignment of some homework, or exercises that the client will do during the week and which will be discussed together in the next session. After a quick check of the patient’s mood, an agenda is set, establishing the topics to be discussed in the session. In a collaborative way, the problems will be addressed with the most appropriate techniques. Then we will move on to the assignment of some homework, or exercises that the client will do during the week and which will be discussed together in the next session.
The techniques used in a Cognitive Behavioral Therapy
The interventions of Cognitive Behavioral Therapy are based on the use of numerous techniques aimed at modifying non-functional behaviors, emotions and cognitions. They derive from the integration of the cognitive model with the behavioral paradigm and include: problem-solving , decision-making , behavioral experiments , monitoring and scheduling of activities , distraction and refocusing , relaxation techniques , gradual enteroceptive and in vivo exposure (e.g., for panic disorder) and exposure with prevention of response(for obsessive-compulsive disorder), role-playing , assertive training , and many more. Belonging to the cognitive paradigm are cognitive restructuring , the use of alternative interpretations and counters , coping cards , the descending arrow technique , the analysis of advantages and disadvantages , the cognitive continuum , acting “as if” , the Socratic dialogue , etc. The Cognitive Behavioral Therapy it also provides specific protocols and guidelines aimed at treating individual psychological disorders.
The importance of homework in Cognitive Behavioral Therapy
The homework is one of the principal features of Cognitive Behavioral Therapy . By doing homework at home between sessions, the patient will have the feeling that he is the architect of his own well-being because he experiences the ability to achieve changes and this leads to an increase in the sense of self-efficacy. Furthermore, “touching” what is done in the session strengthens the credibility and reliability of the therapy.
We are not in school! The homework must in fact be agreed upon and not imposed. They are consistent with the work done in the session with the therapist, they are clear and definitive and in no way will they be a reason for judgment towards the patient.
Cognitive Homework
- Bibliotherapy: readings that help to better understand one’s psychological distress;
- Listening: record the sessions in order to reflect on their content even after the therapy session
- Writing: filling out cards and diaries to learn to recognize and respond to your thoughts more effectively
- Mentalimagery: Imagining yourself facing situations where you fear you may not succeed
Behavioral Homework
- Activityplanning: Increase activities and reduce rumination about negative thoughts
- Step-by-step tasks: Break down problems into smaller, manageable steps
- Behavioral Experiments: Testing one’s thoughts and beliefs
Will I have to take any medications?
The appropriate use of psychotropic drugs is not excluded in Cognitive Behavioral Therapy , indeed, for some specific disorders, the therapy is more effective if associated with the intake of drugs. This will depend on the nature and severity of the client’s complaint. In some cases, the therapist may find a psychiatric consultation useful, and eventually they can agree on the prescription of drugs. The intake and effects of the drugs will be discussed in the therapeutic sessions.
How will I know if the therapy is working?
Most people who undergo therapeutic treatment experience improvement within the first three to four weeks of starting therapy, as long as they attend sessions with motivation and commit to homework consistently. The benefits of the therapy can be verified through the periodic administration of some tests aimed at measuring the emotional state of the client.
