Cognitive Behavioral Therapy (CBT) is the current "gold standard" of psychotherapy treatments and serves as the foundation for many of the new "cutting edge" mindfulness based therapy modalities such as Dialectical Behavioral Therapy (DBT) and Acceptance and Commitment Therapy (ACT).
Because CBT is so common, it has become kind of unglamorous. It's like the workaday, "la-di-sensible", "cargo shorts and flip flops" of the psychotherapy world.
To say you're a CBT therapist is like saying that your hobby is watching television, or that your favorite author is John Grisham, or that you're a New York Yankees fan.
Not that there's anything wrong with all that, but it's just not considered very, how you say, ummmm..... interesting?
So I'm actually saying a whole lot when I tell you that professor Jason M. Satterfield is so fucking good, that he makes CBT into about the most fascinating subject since Dan Blizariean* and the cataclysmic pole shift hypothesis** combined.
* considered by many/some/at least one person (citation needed) to be the most interesting man on Instagram.
**listed (by a web sight) as one of the most interesting subjects on the Internet (and it's actually is pretty interesting - Google it for yourself if you don't believe me).
Anyway.
Professor Satterfield makes CBT phenomenally interesting.
How does he do it?
He pretty much just does a really good job of explaining and demonstrating it.
As it turns out, CBT is actually really fuckin' neat and we're all just sort of jaded or under informed or something.
If you really take a close look. CBT is an amazingly developed, incredibly broad and actually quite deep psychotherapeutic modality.
Plus there's tons of experimental data to back it up.
Unlike its Freudian psychoanalytic predecessors, CBT is light on theory and heavy on evidence i.e. it's been found to be effective (significantly better than placebo) in hundreds of randomly assigned, double blind, placebo controlled trials (RCT's).
In other words, CBT is essentially the thing that makes psychotherapy not just another homeopathy or (insert other quasi medical practice that is pretty much 100% placebo effect).
Again, not that there's anything wrong with placebo effects. A lot of evidence demonstrates that all therapeutic, psychopharmacological, medical and even surgical interventions rely on the placebo effect (to some extent).
Placebo effects are powerful and rad and we'd be fucked without them. But I think we'd all agree that we would like our (expensive and time consuming) therapy to be more effective than a sugar pill (or being on a wait list as it were), and according to the data, CBT achieves this bench mark, distinguishing it from many other psychotherapy modalities that quite simply don't.
Good to know right?
Anyway.
That's a really unnecessarily long way of saying that this is an absolutely top shelf primer on Cognitive Behavioral Therapy.
I think it will be useful for clinician and client alike. But even if you're neither, I believe almost everyone could benefit from this program.
However, it is over 12 hours long, and it's like 25.00 or something. So if you're interested, please allow me to give you some of the highlights so that you can make a maximally informed purchase.
What exactly is Cognitive Behavioral Therapy?
CBT is a short-term, goal-oriented psychotherapy treatment that takes a practical approach to problem-solving and symptom reduction.
CBT assumes that people suffer from unpleasant feelings and moods (e.g. anxiety and depression) because they have inaccurate or unhelpful ways of thinking (cognitive distortions) and maladaptive (negative, harmful etc.) behaviors.
CBT focuses on identifying and restructuring distorted cognitions as well as activating adaptive behaviors, all with the intention of reducing psychopathological symptoms and (dare we say) increasing positive affect.
In other words. CBT is about changing the crazy shit you do and think so you quit feeling like shit and maybe even start feeling nice.
That seems reasonable, right?
Forgive the horrendous cliché but, it ain't rocket science.
It's actually one of the big strengths of CBT. It's theoretical foundations are very simple and commonsensical.
CBT emerged form the Behaviorist tradition that began with Ivan Pavlov and John Watson and later B.F. Skinner.
As (psychology 101) legend has it, Pavlov rang a bell as a signal just before feeding an experimental subject dog (oh fuck, better call PETA right? Don't bother, it was like 150 years ago when he did all this shit. Dogs are almost never use as test subjects now a days).
After months of this dinner bell stimulus, the dog became conditioned to salivate at the mere sound of the bell instead of only in the presence of the food. The bell tone stimulus had been associated (paired) with the food stimulus.
If this sounds analogous to how your pet freaks out when you jiggle the food bag or leash, you're right. It's also the action behind your own shopping behavior when you pass by the ice cream section at whole foods.
I'm sure many of you are not exactly wowed by the insight that environmental stimuli can become associated with and elicit basic physiological and behavioral responses. But at the time it was a HUGE discovery, and it lead to a whole theory of learning called Classical Conditioning.
Classical Conditioning:
Asserts that if an neutral stimuli is paired with an unconditioned stimuli, over time, the neutral stimuli becomes "conditioned" to elicit the same response as the unconditioned stimuli.
Of course Classical Conditioning is not limited to Food and Sound stimuli. It's literally happening all the time, in all sorts of contexts, with all sorts of (internet porn*) stimuli.
* Rapidly becoming the cheapest joke in western culture. Just as all (on line and many off line) arguments lead to an inevitable use of Hitler as an example of bad behavior. All humor (on and off line) is increasingly (and will soon inevitably) include a reference to internet porn.
Later on, Behaviorists under the leadership of B.F. Skinner began experimenting with how behaviors are "shaped" via punishment and reward. They referred to this type of learning as Operant Conditioning.
Operant Conditioning:
The theory asserts that the animals behavior "operates" on the environment (i.e. causes shit to happen).
If the consequences of the behavior are favorable, the animal (including us) will be more likely to repeat the behavior. If the consequences are aversive, than the animal will be less likely to repeat the behavior.
Another way of saying this is:
Desirable consequences increases the likelihood that the behavior will be repeated in the future.
Undesirable consequences decrease the likelihood that the behavior will be repeated in the future.
This "behavioral shaping" process can happen all at once (with big rewards or punishment) or a little bit at a time (with tiny little treats or lil baby electrical shocks).
Behavioral Therapy:
The clinical implications of Classical and Operant Conditioning are relevant to behavioral issues such as addiction and eating disorders where learned associations trigger deeply unconscious (implicit) motivational processes and highly automatic behavior.
Behavioral Therapy was (and still is) wildly effective.
To this day, most psychotherapeutic interventions for eating disorders, addiction, and even anxiety and depression primarily employ Behaviorist principals in order to "retrain" the maladaptive (problem) behavior.
The Behaviorists assumed that:
(A) antecedent events cause (B) behaviors, which have (C) consequences.
If you wrote it out it would look something like this:
A=>B=>C
Behavioral Therapy intends to analyze and modify behaviors via the principals of Behaviorists learning theory i.e. Classical and Operant Conditioning.
In a nutshell, Behavior Therapy assumes that if you don't like the (C) consequences, than change the (B) behavior by either removing the (A) antecedent stimuli, or by rewarding the desired behavior and punishing the undesirable behavior.
For example:
If someone is addicted to drugs:
Than remove the triggering (A) antecedents and engineer a system of (C) consequences that reward (increase likelihood of) desired (B) behavior and punish (decrease likelihood of) undesirable behavior.
This is the logic behind most drug treatment to this day.
You get them away from using friends and remove triggering stimuli like drug paraphernalia by shipping them to Utah or Hawaii or some shit. Than reward sobriety by giving them more freedom or what ever. And you punish relapse by restricting freedom.
Behavioral Therapy assumed that if you changed a persons behavior, than you're done. Problem solved. It also has the added benefit of not necessitating subjects to talk about their feelings or childhood (or really anything for that matter).
But what about memories, beliefs, thoughts and feelings?
How do they factor in to human behavior?
The tacit assumption of Behavioral therapy was that thoughts don't really matter too much. Additionally it was assumed that if you change the behavior that's causing the undesirable consequences, than the person will probably feel better. But the Behaviorists weren't necessarily all that interested in feelings per se.
In fact it's kind of hard to tell if the Behaviorists gave a rats ass about how people feel.
A lot of evidence suggests that they didn't.
But most people sure do seem to care about how they feel and in fact most people report to therapy because they feel like shit and want to feel better.
Furthermore, as in the example of addiction treatment, if a person is self medicating for depression or anxiety (the problem) and you remove the drugs (the dysfunctional solution) than you still have the original problem, and you run the risk of probable relapse.
So Behaviorism and Behavioral Therapy had some serious short comings. And In the early to mid 1960's, strict (radical) behaviorism and Behavioral Therapy got a massive facelift after psychologists, linguists and computer engineers started developing information theory and cognitive science.
The Cognitive Revolution:
Cognitive Theory asserts that, in the case of language adapted animals (people) culturally and linguistically informed core beliefs, procedural (if/than) scripts and internal dialog (self talk) all play a significant role an individual's emotions and behavior.
Beck's Cognitive Theory:
CBT founder Aaron "Tim" Beck posited that it's not the events in our lives that trouble us, it's the view we take on these events that dictate our reaction.
In Beck's model, we have an activating (anticedent) event, followed by automatic thoughts (and feelings), which are proceeded by emotional and behavioral consequences.
A (antecedents) B (beliefs) C (consequences)
ABC
WARNING: This is another (totally different but related) ABC Thing. There are a lot of these ABC things in CBT, so it can get confusing, but the idea for this one is:
(A) antecedent events, trigger
(B) automatic thoughts and beliefs, which trigger (C) consequences, which become the
(A) antecedent event for the next
(B) automatic thoughts and beliefs,
(C) consequences, which become the......
- ad infinitum.
This psychotic merry-go-round of thinking, feeling and doing chugs along, on and on, and the ultimate output is the miracle/mystery we call human behavior.
In this model Human Behavior looks like this:
(A) antecedent events
(B) automatic thoughts and beliefs
(C) consequences, which become the
- repeat
Or:
A=>B=>C=>A=>B=>C= (on and on till you die)
Beck postulated that specific kinds of (B) automatic thoughts and beliefs are linked to certain kinds of emotional and behavioral reactions.
For instance:
Anger is typically preceded by thoughts and beliefs that some injustice or unfairness has been committed, or some type of violation has occurred.
Depression is often preceded by thoughts about loss and/or about powerlessness (hopelessness and helplessness as we say in the biz).
These beliefs and thoughts may be absolutely reasonable, but it's important to note that two different people in the same situation may have two totally different beliefs and automatic thoughts, with really different emotional and behavioral consequences.
Beck asserted that if a person has certain unhelpful or inaccurate beliefs (CBT calls these "Cognitive Distortions") that are making them feel anxious and/or depressed, than if we strategically changed their way of thinking, they will feel less depressed and anxious (CBT calls this Cognitive Restructuring).
In other words, if you can teach an anxious and depressed person to think like a not anxious and depressed person, than they won't be anxious and depressed anymore.
That seems reasonable right?
Like I said earlier, it ain't rocket science.
But (as you may have noticed) changing the way a person thinks is hard.
In order to do it in a meaningful way, we may have to deconstruct thinking into its component parts.
Core Beliefs:
Core Beliefs are basic, implicit assumptions about the (S) self, (O) others and your (F) future.
These Basic Core Beliefs about Self, Others and the Future all effect each other "tri-directionally"
In other words. Your Core Beliefs about Self, Others and your Future are in a three way love triangle, each one being interdependent upon and effecting the other.
It looks sort of like this:
Core Beliefs Triangle:
(S)
/ \
(O) __ (F)
S: self
O: others
F: future
Maladaptive Core Beliefs:
We all have core beliefs about our selves i.e. who we are and what we're capable of. How we stack up in comparison to others. What's fair and what isn't fair. How the world works, what we have to do in order to survive and what our future in it will be like.
Ideas and Beliefs have value based on their:
1. Functionality
2. Accuracy
Hopefully our core beliefs are functional and at least somewhat accurate. But sometimes they are neither. Sometimes they are dysfunctional and inaccurate.
We all acquired our core beliefs at some point, and ideally these are changing and growing as we change and grow.
But sometimes they don't. Sometimes we learn something in one context (i.e. in childhood) and we maintain these core beliefs into other different contexts (i.e. adulthood), even when they are dysfunctional (maladaptive) and inaccurate (distorted).
Maladaptive Core Beliefs:
Having very strong maladaptive or distorted core beliefs can lead to some really bad problems like:
- I'm unlovable => low self-esteem
- Everyone leaves me => intimacy problems
- I always choke under pressure => anxiety
- The future is hopeless => depression
When a young person is subjected to abuse or neglect it's difficult (if not impossible) for them to understand that their abuser is at fault.
The abused or neglected child often internalizes the core belief that they are somehow at fault.
In these circumstances, he/she often adopts the implicit (unconscious/automatic) belief that:
- I'm unworthy of love
- My loved ones and care givers won't be there for me when I need them.
These core beliefs may become the foundation of low self esteem or insecure attachment in adult relationships.
When a young person is subjected to a chaotic environment he/she often adopts the implicit (unconscious/automatic) belief that:
- I am incompetent
- The world is dangerous and overwhelming
These core beliefs can become the foundation for depression and anxiety in adult life.
They can also be the foundation for a multitude of other Cognitive Distortions.
Cognitive Distortions:
Cognitive Distortions are unhelpful and inaccurate ways of thinking that unnecessarily increase distressing feelings and maladaptive behaviors.
Here is a few of the more common ones (Google Cognitive Distortions for a complete list):
1. All or nothing thinking:
Seeing things in black or white as opposed to shade of grey.
Example: thinking "either your with me or your against me"
2. Overgeneralization:
Making hasty generalizations from insufficient experiences and evidence.
Example: thinking "everyone from Dallas is a drugged out train wreck" because a few (or a lot of) people you know from Dallas fit that description (to a tee).
3. Filtering:
Focusing entirely on negative elements of a situation, to the exclusion of the positive.
Example: thinking "this salmon is a little over cooked" at a free lunch.
4. Mind reading:
Assuming that you know what another person is thinking or what they will think.
Example: thinking "if I say hi to her she will think I'm a creep".
5. Catastrophizing:
Giving greater weight to the worst possible outcome, however unlikely.
Example: thinking "if I don't get my car back by Thursday I will die and my life will explode".
What to do about Cognitive Distortions:
Most people recognize that hey engage in at least some of these ways of thinking at least some of the time.
But some people engage in a lot of this types of maladaptive thinking a lot of the time.
Either way It can be a huge problem.
Cognitive Restructuring:
As mentioned earlier. CBT assumes that if you identify and change these Maladaptive Core Beliefs and Cognitive Distortions (referred to as Cognitive Restructuring) than the person is going to feel a bunch better.
But it's not all about Cognitive Restructuring. Beck still views behavioral change as important.
WARNING: one more ABC thing.
In Beck's view (A) affects, (B) behaviors and (C) cognitions all "tri-directionally" effected each other.
Remember the Core Beliefs "love triangle"?
It's another one of those smashed up with another ABC thing.
It looks like this:
The Cognitive Behavioral Triangle
(A)
/ \
(B) __ (C)
A: affect i.e. feelings, emotions etc.
B: behaviors
C: cognition, thoughts, mental images, beliefs (see core beliefs)
The idea is:
Feelings and Thoughts effect Behaviors
But more importantly to CBT
Behaviors and Thoughts effect Feelings
So if you really want to change how you feel, you have to change what you think and what you do.
Bringing it Back to Behavior:
Remember. CBT didn't replace Behavioral Therapy, it just sort of added (integrated) the cognitive component.
Here is the part of CBT that retained and refined all of the behavioral interventions.
Behavioral Activation:
Refers to any behavioral modification based on the Skinnerian (Operant Conditioning) model of behavior change.
The idea is to systematically increase the frequency of adaptive behaviors through reinforcement and reduce the frequency of maladaptive behavior through extinction.
In other words:
Behavioral Activation for depression entails getting the depressed person to do more shit they like that makes them less depressed (like exercise) and do less shit that makes them depressed (like laying in bed all day long).
You get the general idea.
Again, not exactly rocket science.
Easy to understand.
But surprisingly difficult to implement.
Particularly with anxious and depressed people.
Anyway. I could (clearly) go on and on.
This review was actually about four times as long.
I had to edit a bunch of it out in order to post it to Goodreads.
But at least you now have a general outline of what CBT is.
If you're curious as to how (exactly) it works, and what you actually do in session, than by all means GET THIS COURSE.
I can't say enough good stuff about it. Again, the instructor is absolutely top shelf. The material is excellent, and the presentation is spectacular.
You literally can't go wrong.
Five stars!!!!!