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Straight Up Guide to Cognitive Behavioral Therapy (CBT)

These guides were born out of Noah and Christine’s frustrations with overly complicated and jargon-filled articles, newsletters, books, and therapy websites. Our mission is to create clear and practical guides in order to learn, grow from challenges, and lead more meaningful and impactful lives.

Cognitive Behavioral Therapy (CBT)

Cognitive behavioral therapy, or CBT, is a therapeutic approach that addresses distorted thinking, dysfunctional emotions, and maladaptive behaviors through goal-oriented interventions. The name refers to the integration of cognitive therapy and behavior therapy that CBT practitioners use with their patients. CBT is based on the cognitive model of psychopathology, which proposes that dysfunctional thinking, which influences the patient’s mood and behavior, is the source of psychological disturbances (Beck, 2011). However, CBT is almost always practiced with behavior therapy principles, and behaviorists would add the idea that maladaptive behavior reinforcement also produces psychological problems (Gehart, 2013).

As proposed by one of CBT’s leading theorists, Aaron Beck, and further articulated by his daughter, Judith Beck, the cognitive model describes how an individual’s spontaneous thoughts about a given life event, called automatic thoughts, fuel his or her emotional and behavioral reactions. CBT posits that automatic thoughts derive from core beliefs activated by life events to produce distorted thinking, maladaptive behaviors, and problematic emotions (Persons, 2008). Core beliefs, which vary in accuracy and functionality, are the result of an individual’s interactions with the world and other people, and are influenced by their genetic predisposition (Beck, 2011). Beck theorized that negative core beliefs essentially fall into two broad categories: those associated with helplessness and those associated with unlovability (Beck, 2011). A third category, associated with worthlessness, has also been described (Beck, 2011).

The usual course of treatment in cognitive behavior therapy involves an initial emphasis on identifying and modifying “automatic thoughts” that derive from the core beliefs. Automatic thoughts are reflex-like thoughts that automatically come to mind when a particular situation occurs. Automatic thoughts are learned, tend to “catastrophize” any situation, and are almost always believed by the individual. CBT therapists teach patients to identify these cognitions that are closest to conscious awareness, and to gain distance from them by learning how they might be distorted. Common cognitive distortions include mind reading, fortune telling, catastrophizing, labeling, discounting the positives, and negative filter, although there are many more.

The CBT model for change is straightforward. Since one’s thoughts and core beliefs were learned, they can also be unlearned, and more reality-based and functional new beliefs can be developed and strengthened through treatment. The fundamental assumption of CBT is that it is the individual’s interpretationof an event, not the event itself, that influences how he or she feels and behaves. If one can change the way one interprets an event, one can change the way one feels and behaves in reaction to it. In CBT, the therapist introduces interventions though cognitive restructuring to modify thinking patterns, meditation or relaxation for emotional regulation, and behavioral changes to combat maladaptive behaviors. The CBT therapist will use a combination of cognitive and behavioral interventions, thus leaving a fair degree of flexibility to the clinician. Cognitive restructuring might include thought records, identifying distortions, reframing, and cost-benefit analysis of various beliefs. Behavioral changes might include scheduled activities, limited exposure, and graded task assignments. CBT allows that either cognitive or behavioral interventions can effect change and lead to a reduction in symptoms.

CBT requires a sound therapeutic alliance in order to work, and emphasizes collaboration and active participation (Beck, 2011). The patient/therapist relationship in CBT is based on collaborative empiricism. The therapist and the patient work together to examine, test, and modify the patient’s thinking and behavior and develop more adaptive responses. The therapist’s role is to help the patient recognize his or her idiosyncratic style of thinking and modify it through the application of evidence and logic. CBT posits that just because an individual believes something does not necessarily mean it is true. Changing one’s thinking so it is more reality-based and useful helps one feel better and progress toward one’s goals. CBT focuses primarily on the present, and is not overly concerned with the origin of a problem. Instead, it focuses on what maintains the problem in the present, and how the patient thinks about the past in the present. CBT allows individuals to change their responses to people, places, and things, and worry less about forces beyond their control. CBT is problem-focused and action-oriented. It focuses only on what one can change.

References

Beck, J. S. (2011). Cognitive behavior therapy: basics and beyond (2nd ed.). New York: Guilford Press.

Gehart, D. (2013). Theory and treatment planning in counseling and psychotherapy. Belmont, California: Brooks Cole.

Leahy, R. L. (2003). Cognitive therapy techniques: a practitioner’s guide. New York: Guilford Press.

Persons, J.B. (2008). The case formulation approach to cognitive-behavior therapy. New York: The Guilford Press.

Christine Izquierdo and Noah Laracy are the co-founders of Straight Up Treatment, an anxiety disorder specialty treatment center. Straight Up Treatment utilizes a variety of cognitive-behavioral approaches to treat anxiety-based conditions such as Obsessive-Compulsive Disorder, Social and Performance Anxiety, Panic Disorder, Depression, and Generalized Anxiety.

You can learn more about them here.

You can read more guides here.

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Straight Up Guide to Types of Therapy

These guides were born out of Noah and Christine’s frustration with overly complicated and jargon-filled articles, newsletters, books, and therapy websites. Our mission is to create clear and practical guides in order to learn, grow from challenges, and lead more meaningful and impactful lives.

If you go to a western medical doctor with the flu, chances are you will get antibiotics. However, in the world of psychotherapy, things are more complicated. There are a number of different “orientations,” or styles, that view human beings in different ways, and provide different models of how to treat anxiety, depression, and other mental health issues. While there are apparently over 400 different orientations, this article will review a number of the most notable ones, and what their mechanism for change is.

Psychodynamic

This is what therapy is traditionally thought of, deriving from Sigmund Freud, and focusing on the unconscious. The traditional form of this is called psychoanalytic psychotherapy, which involves the patient lying on the couch and free associating. Sessions are two to five times a week for several years. Psychodynamic therapy is the modern adaptation of this form, and occurs roughly once a week. This is a non-directive form of therapy, meaning that there is no predetermined goal or direction within a session. This therapy tends to be focused on the past and how it is showing up in the present. There is a great deal of variety within this orientation with a number of different “schools” such as Object Relations, Ego Psychology, or Self Psychology, but they all come from the same lineage.

Change Mechanism: The unconscious is made conscious, and this insight leads to change. Psychodynamic therapy also relies on “corrective emotional experiences” in which past traumas are healed in session.

Cognitive Behavioral Therapy (CBT)

This is a therapeutic approach that addresses distorted thinking, dysfunctional emotions, and maladaptive behaviors through goal-oriented interventions. The name refers to the integration of cognitive therapy and behavior therapy that CBT practitioners use with their patients. CBT is a directive form of therapy in which the therapist will collaborate with the patient to establish goals and direction for each session. CBT tends to be present-focused, and spends less time than psychodynamic on the past.

Change Mechanism: Since thoughts and behaviors have been learned, they can also be unlearned and modified in treatment.

Acceptance and Commitment Therapy (ACT)

This is a relatively new form of CBT that emphasizes psychological flexibility as the key to mental health. ACT relies on mindfulness and experiential exercises as opposed to the logic and reasoning used often in CBT. Acceptance means not trying to control events, people or internal states. Commitment means taking action toward people or things you value, regardless of how you may feel at the moment. ACT emphasizes behavior change over insight, and learning to live with pain as opposed to trying to control it.

Change Mechanism: By moving towards things you value, and not avoiding difficult feelings, your life becomes more meaningful over time.

Dialectical Behavior Therapy (DBT)

This was developed by Marsha Linehan to treat Borderline personality but has been adopted for more general use. DBT is a skills-based treatment that focuses on four areas: 1) Mindfulness, 2) Distress tolerance, 3) Emotion regulation and 4) Interpersonal effectiveness. Mindfulness refers to the art of observing one’s mind non-judgmentally. Distress tolerance means how to more effectively cope with emotional pain when it arises. Emotion regulation means learning how to identify your feelings and take appropriate actions when they arise. Interpersonal effectiveness means learning how to be assertive, advocate for change, and say “no.” Group and individual session are utilized in DBT, and phone sessions are available when necessary.

Change Mechanism:  If you can develop new skills to employ during your most difficult intense emotional moments, your life inevitably will get better.

Exposure and Response Prevention (ERP)

This is a highly specialized form of behavioral therapy in the CBT school that was originally developed to treat phobias and OCD, but is now used across a variety of anxiety disorders. Exposure means gradually moving closer to what you fear or are avoiding – this could be dirt, germs, spiders or heights, or more abstract mistakes, unevenness, or even “bad” thoughts. Response Prevention means that you modify or “prevent” your usual response to these fears, i.e. compulsions or avoidance, and learn to tolerate the discomfort that the exposure brings.

Change Mechanism: If you expose yourself to your greatest fears, and respond in a different way than you are used to, you can overcome them.

Family Systems

This orientation views people primarily through a “systems” lens, meaning as part of a greater system than themselves, usually their family. Systems therapists view individuals as part of a complex series of interlocking parts and relationships that affect each other in various ways. Some Systems therapists prefer to meet with family members individually, while other will meet with the entire family, or some combination. Family systems is often used in conjunction with CBT or more individually-minded orientations.

Change Mechanism: If you change any part of the system, meaning any individual member, then the entire system will have to respond in some way.

These are just a few of the most well-known orientations, but there are many others that are not on this list. It might be helpful to have a discussion with any potential therapist or mental health practitioner and ask what their orientation is, and why they chose that one over the others. It might be helpful to ask how their orientation will show in up treatment.

Christine Izquierdo and Noah Laracy are the co-founders of Straight Up Treatment, an anxiety disorder specialty treatment center. Straight Up Treatment utilizes a variety of cognitive-behavioral approaches to treat anxiety-based conditions such as Obsessive-Compulsive Disorder, Social and Performance Anxiety, Panic Disorder, Depression, and Generalized Anxiety.

You can learn more about them here.

You can read more guides here.

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Straight Up Guide To Mental Health Professionals

These guides were born out of Noah and Christine’s frustration with overly complicated and jargon-filled articles, newsletters, books, and therapy websites. Our mission is to create clear and practical guides in order to learn, grow from challenges, and lead more meaningful and impactful lives.

When we first began looking at graduate schools in psychology, we remember being confused as to what the various titles, degrees, and licenses all meant. This is the article we wish we could have read at that time. The mental health field and the various labels of mental health practitioners are organized around the amount of education and degree earned, as well as the license is given on a state level.

Psychiatrist

This is someone who went to medical school and then specialized in mental health. They typically go to medical school for four years, and then attend residency for an additional four years. Psychiatrists primarily treat their patients through medication and their sessions are centered around diagnosis, medication, and medication management. Some psychiatrists can do therapy, but this tends not to be the focus of their practice. Having gone to medical school, they often to view things through a biological lens.

Education: 4 years of medical school, and 4 years of residency.

License/Title: MD, Doctor of Medicine

Clinical Psychologist

These are doctoral-level clinicians, either with a Psy.D. or Ph.D. at the end of their name. Psy.D..  (Doctor of Psychology) programs tend to be more clinically-oriented, meaning that they focus on the treatment of patients. Ph.D (Doctor of Philosophy) programs tend to focus more on research. Psychologists have training in assessment, which is the art and science of testing, and most have to write dissertations. Psychologists practice from a variety of different orientations, or styles, that vary greatly.

Education: 4-6 years of graduate training plus 1-2 years of internship.

License/Title: Psy.D. or Ph.D., both are referred to as Psychologist.

Therapist

A therapist is a master’s level clinician, or MFT, who specializes in treating couples and families. They have a different license than psychologists, and do not have training in assessment. They are trained in what is referred to as “Family Systems” – meaning that they can treat the family and its interlocking parts as well as individuals.

Education: 1-2 years of graduate training plus 1-2 years of internship.

License/Title: MFT, Marriage and Family Therapist

Social Worker

Licensed social workers or LCSWs, who have a master’s degree in social work. They tend to specialize in case management and in helping people access services through various agencies, but many have branched out into doing therapy.

Education: Two years of graduate training plus 1-2 years of supervised experienced.

License/Title: LCSW, Licensed Social Worker

Psychoanalyst

This is a psychiatrist, psychologist, therapist, social worker or other mental health professionals who has undergone additional training in psychoanalytic psychotherapy, which is the type that Freud and Jung practiced. These programs are often five years in length but the states have not officially provided the license or sanction.

Education:  5+ years of post-graduate training.

License/Title: Can call themselves “psychoanalyst,” but not an official license.

Behavior Analyst

These are practitioners who use behavior analysis to treat people. They frequently work with people with autism, but not exclusively. They use positive reinforcement and negative reinforcement (desirable consequences), and positive and negative punishment (undesirable consequences) to increase and decrease the frequency of a behavior.

Education:  Two years of graduate training.

License/Title: ABA or BCBA

Drug Counselor

These are certified drug counselors who work primarily with the substance abuse population. They tend to recover themselves, but it does not require.

Education:  Varies greatly by state.

License/Title: CADC (Certified Alcohol and Drug Counselor)

Life Coach

Life Coaches have varying amounts of training but no specific degree or license. It can be effective for motivating people, holding them accountable, and even working on specific behaviors. However, they don’t have adequate training to treat most mental health issues.

Education:  None required

License/Title: N/A

All things being equal, more training is probably better than less training. However, it is not the only thing important in finding a mental health professional. Years of experience count for something, as does the amount of personal work that a person has done. There is a great deal of variation in the quality of mental health professionals, and it is a personal decision for each individual.

Christine Izquierdo and Noah Laracy are the co-founders of Straight Up Treatment, an anxiety disorder specialty treatment center. Straight Up Treatment utilizes a variety of cognitive-behavioral approaches to treat anxiety based conditions such as Obsessive Compulsive Disorder, Social and Performance Anxiety, Panic Disorder, Depression, and Generalized Anxiety.

You can learn more about them here.

You can read more guides here.