John Winston Bush, PhD
New York Institute for Cognitive and Behavioral Therapies
Just what is CBT? How does it work?
Cognitive behavior therapy* combines two very effective kinds of psychotherapy — cognitive therapy and behavior therapy.
Behavior therapy helps you weaken the connections between troublesome situations and your habitual reactions to them. Reactions such as fear, depression or rage, and self-defeating or self-damaging behavior. It also teaches you how to calm your mind and body, so you can feel better, think more clearly, and make better decisions.
Cognitive therapy teaches you how certain thinking patterns are causing your symptoms — by giving you a distorted picture of what's going on in your life, and making you feel anxious, depressed or angry for no good reason, or provoking you into ill-chosen actions.
When combined into CBT, behavior therapy and cognitive therapy provide you with very powerful tools for stopping your symptoms and getting your life on a more satisfying track.
CBT is active therapy
In CBT, your therapist takes an active part in solving your problems. He or she doesn't settle for just nodding wisely while you carry the whole burden of finding the answers you came to therapy for.
You will receive a thorough diagnostic workup at the beginning of treatment — to make sure your needs and problems have been pinpointed as well as possible.
This crucial step — which is often skimped or omitted altogether in traditional kinds of therapy — results in an explicit, understandable, and flexible treatment plan that accurately reflects your own individual needs.
In many ways CBT resembles education, coaching or tutoring. Under expert guidance, as a CBT client you will share in setting treatment goals and in deciding which techniques work best for you personally.
Structured and focused
CBT provides clear structure and focus to treatment. Unlike therapies that easily drift off into interesting but unproductive side trips, CBT sticks to the point and changes course only when there are sound reasons for doing so.
As a CBT client, you will take on valuable “homework” assignments to speed your progress. These tasks — which are developed as much as possible with your own active participation — extend and multiply the results of the work done in your therapist's office.
You may also receive take-home readings and other materials tailored to your own individual needs to help you continue to forge ahead between sessions.
What else is different about CBT?
Most people coming for therapy need to change something in their lives — whether it's the way they feel, the way they act, or how other people treat them. CBT focuses on finding out just what needs to be changed and what doesn't — and then works for those targeted changes.
Some exploration of people's life histories is necessary and desirable — if their current problems are closely tied to “unfinished emotional business” from the past, or if they grow out of a repeating pattern of difficulty. Nevertheless, 100 years of psychotherapy have made this clear...
Past vs. present and future
Focusing on the past (and on dreams) can at times help explain a person's difficulties. But these activities all too often do little to actually overcome them. Instead, in CBT we aim at rapid improvement in your feelings and moods, and early changes in any self-defeating behavior you may be caught up in. As you can see, CBT is more present-centered and forward-looking than traditional therapies.
The levers of change
The two most powerful levers of constructive change (apart from medication in some cases) are these...
- Altering ways of thinking — a person's thoughts, beliefs, ideas, attitudes, assumptions, mental imagery, and ways of directing his or her attention — for the better. This is the cognitive aspect of CBT.
- Helping a person greet the challenges and opportunities in his or her life with a clear and calm mind — and then taking actions that are likely to have desirable results. This is the behavioral aspect of CBT.
CBT: The therapy with by far the most research support
CBT has been very thoroughly researched. In study after study, it has been shown to be as effective as drugs in treating both depression and anxiety.
In particular, CBT has been shown to be better than drugs in avoiding treatment failures and in preventing relapse after the end of treatment. If you are concerned about your ability to complete treatment and maintain your gains thereafter, keep this in mind.
Other symptoms for which CBT has demonstrated its effectiveness include problems with relationships, family, work, school, insomnia, and self-esteem. And it is usually the preferred treatment for shyness, headaches, panic attacks, phobias, post-traumatic stress, eating disorders, loneliness, and procrastination. It can also be combined, if needed, with psychiatric medications. (See next section.)
No other type of psychotherapy has anything like this track record in outcomes research.
What about drug treatment?
CBT is usually employed by itself, without psychiatric drugs. For some people, however, drug treatment is needed to obtain a partial reduction in symptoms before CBT can be fully effective. Usually, though not always, it is preferable to try CBT alone before prescribing medications. This is for several reasons:
Benzodiazepine drugs such as alprazolam (Xanax), plus certain other types of tranquilizers, can be habit-forming if taken over a long time or in high doses. This is a complication that needs to be avoided if possible. Despite their reputation as “wonder drugs,” antidepressants such as amitryptaline (Elavil) and fluoxetine (Prozac) work only about 65% of the time. MAOI drugs (e.g., Nardil) carry a risk of hypertensive crisis, stroke or even death if common foods or beverages containing tyramine are unintentionally consumed. Finally, the mood stabilizer lithium carbonate can produce toxic reactions unless it is very carefully monitored.
In addition, research studies have revealed these other facts about drug treatment for depression and anxiety:
- CBT and well-chosen drugs, when each is used alone, are about equally effective during the period of active treatment.
- Adding drug treatment to CBT is not likely to get better results than using CBT alone (except in special cases such as the one described above).
- Treatment failure is more likely when drugs are used, typically because of side effects.
- Relapse after the end of treatment is more likely when only drugs have been used. This is believed to be because drugs, unlike CBT, do not encourage the development of valuable coping and emotional management skills.
In addition, a number of questions have been raised about antidepressant drugs — which are increasingly being prescribed for anxiety conditions as well:
- Whether widespread beliefs about their effectiveness are scientifically justified.
- The side effects and withdrawal symptoms they can produce.
- Their use with children.
- Their safety, especially when used in combination with other psychoactive drugs.
- The theories about depression that support their use.
- Whether they really are as likely to help as well-chosen forms of psychotherapy.
CBT is usually brief
Most CBT patients are able to complete their treatment in just a few weeks or months — even for problems that traditional therapies often take years to resolve, or aren't able to resolve at all.
Meanwhile, for people with complex problems, or who are forced to live in adverse conditions beyond their control, longer-term treatment is also available.
(See discussion of factors affecting treatment length.)
How often will I be seen?
The answer to this question depends on your individual needs, your insurance plan, and the way your own therapist prefers to work.
As a rule, however, most people can expect to begin their treatment with weekly visits.9
A few — particularly if they are in crisis — may begin with two or more sessions a week until their condition is stabilized enough that they can safely come only once a week.
What happens further on in treatment?
Again, the answer depends on how you are progressing, and on your therapist's and your own preferences. These are among the options that are often recommended...
- Individual sessions every other week or monthly, combined with weekly group therapy meetings.
- Individual sessions every other week or monthly, without participation in group therapy.
- A planned break of several weeks, followed by resumption of weekly individual sessions for a period of time.
- A trial termination of therapy — with the option of resuming if the need develops. Quite often, a follow-up session or phone contact is scheduled for a future date.
when you don't
In addition, most CBT practitioners subscribe to the principle of intermittent brief psychotherapy, as and when needed.
In this treatment model — espoused by Dr. Nicholas Cummings, a world leader in therapeutic advancement and former president of the American Psychological Association — you don't “go into therapy” and stay for year after year, regardless of whether you're making significant progress or not.
Instead, you consult your therapist when there's a problem you need professional help with — and not in between. After all, isn't this sensible approach the one you follow with your physician, your dentist, your attorney or accountant, and all those other professionals?
How can I find a CBT professional?
If you are in or near New York City, you can call the Cognitive Therapy Center of Brooklyn (the private practice of John Winston Bush, PhD). The phone number is 718636-5071; if you need to leave a message, please use voice mailbox 1. Or if you prefer, you can send an e-mail inquiry to him at rom CBT Web site visitor. For complete information about Dr. Bush, see his curriculum vitæ(highfalutin academic name for résumé) on this site.
Otherwise, you might want to consult the Center'snational list of CBT providers.
Now, to learn more about CBT . . .
These have been the essentials. To understand more of how CBT works — and why it works so well — click the following link to read A fuller explanation of CBT.
The cognitive side of CBT
Perhaps this will help make it clear. You must have noticed that when you are experiencing an emotion, your body feels different. This is because you're sensing certain distinctive changes in your internal physiology. It's no accident that the word "feeling" can be a synonym for "emotion." In other words (to simplify things a bit)..To have an emotion is to feel the physical (bodily)consequences of our thoughts.
Imagine the following situation:A friend is due to meet you for dinner at your house at 7:00. But it's now past 8:00, and there's been no sign of her — not even a phone call. How are you going to feel about this?
Well, as this diagram makes clear, there's more than one possible answer:
Friend is late for dinner / What you think / How you feel / What you do
"She might have been hurt on the way here." / Worried or anxious / Call hospital ERs to find out if she's there
"She didn't bother to let me know she was delayed." / Annoyed or angry / Chew her out, or act chilly, when she does show up
"It doesn't matter to me whether people are on time." / Indifferent / Nothing in particular
"I needed the time to fix the house up anyway." / Relieved / Relax and enjoy yourself
Now of course there are ways not shown in the diagram in which someone might interpret a friend's being late, and different ways — as a result — in which he or she might react emotionally and behaviorally.
Note also that your thoughts about your friend's lateness don't affect just your feelings — they can also influence the actions you take.
And while it might seem silly to consult a psychotherapist over nothing more than a dinner date, the basic principle is exactly the same when it comes to major and more complex problems.
As the philosopher Epictetus said almost 2,000 years ago:
"The thing that upsets people is not what happensbut what they think it means."
People — and I mean all people, not just patients — routinely distress themselves and others with arbitrary interpretations of what is going on. Sometimes this is done out of blind habit, or under the influence of a bad mood or bodily discomfort; sometimes it happens for quite other reasons. Challenging, and at times changing, one's doubtful interpretations of events is much of the cognitive work of CBT.It's important not to get this confused with the ever-popular practice of "positive thinking." In CBT the goal is accurate and rational thinking — the kind that is based as much as possible on logic and the available facts. Most of the time this does result in a more positive outlook — but there are also times when its value lies in correcting an undesirably rosy view of things.
And now for the other side . . .
So far, we've been looking at how our thinking influences our feelings and behavior. Before going on, however, we also need to look at the converse — how our feelings and behavior influence our thinking.For a wide-ranging review of the first part of this vital topic, see Stanford psychologist Gordon Bower's speech and monograph, Emotion and Social Judgments. (File size is 55KB, but well worth it — there's enough food for thought in this paper to keep you topped up for weeks.)
If something happens to which you automatically and reflexively react with fear or anxiety, your thoughts will tend to be about danger and the consequences of being harmed. Similarly, if your instant reaction to an event is to feel angry or sad or happy — and especially if you also act on your feelings — your thoughts (including your recollections of the past and your vision of the future) will be biased in the same direction
Emotional reactions arise chiefly in a region of the brain called the limbic system, which is very fast-acting and can respond to events on the basis of quick-and-dirty impressions. This nimbleness of response has survival value in some situations — such as noticing a fast-moving object that could be a car or truck approaching as you cross a street.
But on other occasions — such as complex situations where you need to call on more of your accumulated knowledge and experience, speed can be a disadvantage. The more complete information you need at such times has to be processed by the lateral prefrontal cortex of your brain — which gets into gear about half a second later than your limbic system. This short delay is often enough that your thinking, under the influence of an automated emotional reaction, heads off in a biased direction that you may come to regret.
In instances like these, the influence of thinking on emotions can be one of sustaining or amplifying an emotion as opposed to initiating it. (To see how this works, remember some occasion when something made you hopping mad, and you then fed the feeling with minutes or hours of angry thoughts — only to discover later on that there had simply been a misunderstanding.)
In practice, treating this kind of problem clinically involves methods traditionally associated, not with cognitive therapy, but with behavior therapy. To which we now turn.
The behavioral side of CBT
You've probably heard about the Russian physiologist Ivan Pavlov. The one who taught dogs to salivate when they heard a buzzer. Since we're going to be talking about Pavlov's contributions to psychotherapy, you may as well know that he looked exactly like this guy with the cool Edwardian beard....Much, though far from all, of behavior therapy derives from Pavlov's demonstration that events occurring closely together in time are likely to be stored in the brain in a sort of mental package. Because Pavlov set off the buzzer just as he was about to give the dog some food, the buzzer and the food became associated with each other. As a result, after a while the dog began salivating when he heard a buzzer — whether he was given food or not.
The next thing Pavlov discovered was that if he sounded the buzzer too often without coming through with some food, the dog no longer salivated just because there was a buzzer buzzing. This is called, in the jargon of behavior theory, "extinction." It refers to the fact that a conditioned reaction — in humans as well as dogs — can become substantially overridden if it is no longer "reinforced."