Epictetus hit it on the head. The ancient Greek philosopher noted: “Men are disturbed not by things, but by the view which they take of them.” Two millennia later, there is an array of psychological tools at our disposal to help us transform one such view for another.
Structured upon decades-old, empirical research and psychotherapy, cognitive behavioural therapy (CBT) has come of age. Whereas mindfulness chiefly concerns you getting out of your head by raising your awareness to the internal and external experiences of the present moment, CBT is more about understanding that how we think and feel is not automatic or involuntary, nor governed by the unconscious or genetics, but is a process that can be radically changed should we have the will to do so.
While mindfulness can appear at times over the last decade to be inaccurately painted as a panacea for most mental health problems, it is in fact one of several alternatives to cognitive and other talking therapies.
However, problem-focused and action-oriented CBT is about reclaiming from autopilot the sea of unhelpful, unproductive and often unfounded thoughts, beliefs and interpretations (eg magnifying negatives and minimising positives, overgeneralising and “catastrophising”) that can flood us each day, understanding the context from which they have arisen and replacing them with alternative, more realistic and constructive cognitions.
CBT allows you to identify baseless, exaggerated or extreme thinking, routinely ricocheting about your mind, for what it is, while understanding that it really does not have to be this way, unless you want it to. But only you can make that change.
It comes down to the trigger. Were you ever to come across a dead body in the street that just “happened” to be shot, wouldn’t you want to learn who pulled the trigger, when and why? The resulting corpses of our wayward thoughts are similarly susceptible to triggers, often inducing unpleasant physical symptoms (eg butterflies in the stomach, increased heart rate or body temperature) and/or spurring tenuous decision-making and regrettable behaviour – often all in the space of seconds.
However, we have traditionally paid a negligible degree of time comprehending or addressing what those triggers are and how they’ve come to be. The finger which pulls the trigger is marshalled by our core beliefs and these are spawned, but not set, in childhood. CBT can enable us to identify and decode these beliefs that subliminally steer our path through each day and our life.
All about the core
“These are our major beliefs about ourselves, about our world and about other people,” says Galway-based clinical psychologist Dr Clare Kambamettu. “Our core beliefs act like a filter, through which we view everything that happens to us in our lives. They inform how we think about the world, often depending on what happens to us on a daily basis.”
Kambamettu says CBT can be used for both general wellbeing, as well as treating mental health issues such as depression or anxiety.
“But we also know from research that it’s very useful in helping us build self-esteem and stress-response skills, and helping us in our day-to-day lives. From my own experience, understanding how my thoughts make me feel and behave has probably been one of the most helpful skills that I’ve learned throughout my adult life.”
While depression and anxiety are known to be treated most effectively from CBT, it has also been used to treat – with varying results – stress, worry, phobias, panic attacks, obsessive compulsive disorder, eating disorders, anger, pain and sexual dysfunction.
Despite recent research that suggests CBT may not be as effective at it once was deemed to be, Kambamettu stresses most scientific research still supports it as one of the most effective interventions for treating many mental health problems.
“CBT has been shown to be more effective in treating issues such as anxiety disorders than traditional treatments. But when it comes to mild to moderate depression, we know it is equivalent to antidepressant medication, in terms of response and rates of relapse.”
Kambamettu, the director of Lighthouse Clinical Psychology service at Galway Bay Medical Centre, says we are currently experiencing the third wave of CBT, which is stretching into a fourth.
Although cognitive psychotherapy has its roots in ancient philosophy, “CBT started in the 1950s in the United Kingdom and United States. At that point it was behavioural therapy. Psychologists were learning about the impact of behaviours on mental health and on our experiences of the world. Then the second stage, which was called cognitive therapy, took place from about the late 1960s. This is when people started to place more emphasis on the patterns of our thinking, in relation to our behaviour”, she says.
Cognitive and behavioural therapies have merged since the 1980s to become cognitive behavioural therapy. As its techniques are rigorously evaluated, applying scientific evidence rather than anecdote, CBT is now morphing into its fourth dimension: mindfulness-based CBT (MBCBT).
“Mindfulness on its own has not been proven to be an effective intervention for depression or anxiety but mindfulness-based CBT has been proven to do this,” says Kambamettu. “But given that mindfulness, CBT and mindfulness-based CBT are all the buzz words at the moment, and where a lot of research money has been targeted, it’s important to remember that there are many approaches to lots of different types of problems.”
The biopsychosocial model
According to cognitive psychotherapist and chair of the CBT section of the Irish Council for Psychotherapy, Anne Marie Reynolds, everybody can benefit from CBT.
“CBT is based on an individual assessment and conceptualisation of a person’s presenting problem. It also uses Socratic dialogue to assist a person gain insights that can facilitate the change process,” says Reynolds, who adds that how we view events is based on beliefs that have been formed in childhood and are really important in understanding how you are in the world today.
Cognitive psychotherapy adheres to the biopsychosocial model; disease attributed to the complex, variable interaction of biological, psychological and social factors. In layman’s terms: everything is connected.
Depending on the presenting problem, CBT can serve as an effective alternative to antidepressants, says Reynolds, who lectures students on the cognitive psychotherapy masters course in Trinity College.
“So someone who is experiencing suicidal depression, or who is hearing voices, will need medication in conjunction with cognitive psychotherapy. But most anxiety-presenting problems can be treated without medication. Long term, CBT helps the person manage and understand the predisposing factors, so it works at a deeper level.”
Post-traumatic stress disorder is but one case in point: medication will help treat some of the symptoms, but not the underlying trauma of the experience. Similarly, an antidepressant is not likely to change our view of ourselves.
Separating fact from fiction in the thought process
“CBT can be used really effectively for diagnoses such as alcohol treatment, drug abuse, depression or anxiety,” says counsellor and psychotherapist Siobhán Murray.
“What it wouldn’t be used for would be more clinical areas, such as borderline personality disorders. It just wouldn’t make enough of an impact . . . But as with any treatment, somebody has to want to change their behaviour. CBT changes the first thought process, asking if that thought is fact or fiction. Is it based on something real or something they fear happening, in which case it is not fact.”
But what if you’re just naturally a glass-half-empty sort of person?
“We all need a certain level of anxiety in order to motivate us to do certain things. But it’s only when those levels of anxiety impact us, or those around us, on a daily basis that it becomes an issue and needs to be addressed.”
Murray offers a six-week CBT programme, during which deeper issues are sometimes revealed, to be dealt with in later weeks and months. And to help participants avoid slipping back into their old thought patterns after the programme is finished, Murray gets them to journal.
She also suggests that two or three months after the course has finished participants should come back for a final, or near-final, session and possibly again for a final session a few months after that, in order to check in on what are the triggers sending one back to old thought patterns.
“I bring in a lot of gratitude into CBT. It involves daily repetition. You have possibly spent 20 years in a thought pattern that hasn’t been serving you well, and you are now trying to change it in six weeks. It’s about continual practise and been consistently aware of your thought behaviour patterns.”
Telling your psychotherapist from your charlatan
Before committing to CBT, ensure your would-be psychotherapist is suitably qualified, accredited and experienced. In other words, vet him or her like you would for a wannabe employee. Just like with some mindfulness facilitators passing themselves off as “therapists” across the country, some alleged “cognitive psychotherapists” have no training or experience of working in mental health.
“There are a lot of people who call themselves cognitive psychotherapists who are not adequately trained or qualified,” says Reynolds.
“They should have an undergraduate qualification in a relevant, health-related field and a post-graduate qualification to master’s level, which means they have continued professional development, ongoing clinical supervision and engage in reflective practice. That is certainly not the case for everybody who purports to be a practising cognitive psychotherapist.”
The first stop for those interested in CBT is the website of Cognitive Behavioural Psychotherapy Ireland (cbti.ie), an accreditation body for cognitive behavioural psychotherapy. It is part of the umbrella body of the Irish Council for Psychotherapy that represents more than 1,500 psychotherapists in the country.
Similarly, the Irish Association for Counselling and Psychotherapy (irish-counselling.ie) identifies, develops and maintains professional standards of excellence in its professions, serving as a trustworthy link between those looking for counselling/psychotherapy and those who provide it.
When looking for a psychotherapist, don’t be afraid to ask about his or her background, training and experience, no matter what his or her therapeutic modality (eg, psychoanalytical, integrative, constructivist or cognitive behavioural psychotherapist).
However, a cognitive psychotherapist is unquestionably the best suited professional when it comes to CBT. Like in most professions, one size doesn’t fit all.
Next best thing: the online CBT course
The most effective results from CBT arise from several one-to-one sessions with an accredited cognitive psychotherapist, over the course of months, or even years. A multi-week CBT programme will help you learn the skills of CBT, but may not go deep enough in fully understanding the triggers fired off each day by our core beliefs.
Should money and time prevent one-to-one sessions, a third and last (some psychotherapists would argue) option is an online CBT course. Chief among them is on the A Lust for Life website (http://bit.ly/2k3oPx6).
However, treat it and other free online CBT courses as you would a two-minute trailer of a feature-length movie you’d like to see in the cinema – a worthy introductory snippet to encourage you to embark upon the real thing.
In addition, psychologytools.org is an excellent resource for mental health tools, including user-friendly guidelines for CBT.