Cognitive Behavioral Therapy (CBT) is a term bandied around a lot in news stories or any conversation about therapy. There is a lot of scientific support for its efficacy in treating issues such as obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), unipolar depression, anger, and bulimia.
But there is still not perfect consensus among researchers, theorists, and clinicians about what exactly CBT is and what it isn’t. While some disagreements are about whether or not changing cognitions or learning principles (behavioral) are responsible for someone with depression feeling less depressed, some of the confusion is simply due to the variety of cognitive behavioral treatments available.
CBT is often discussed as one monolithic form of therapy, when in fact it is usually used as an umbrella term that includes a variety of different kinds of therapy. Each of these therapies consists of numerous techniques, slightly different models, and different styles or emphases.
Which Therapies Fall Under the Umbrella of “CBT”?
Cognitive behavioral therapies include the following:
- Cognitive Therapy by Aaron T. Beck
- Rational Emotive Behavior Therapy (REBT) by Albert Ellis
- Dialectical Behavior Therapy (DBT) by Marsha Linehan
Without question, there are many common elements, but the differences can be critical. For example, the impetus for Dr. Linehan creating DBT was that when she used traditional CBT to treat chronically suicidal and depressed women, CBT made them worse. On the other hand, cognitive therapy is considered the gold standard for treating depression and has been shown to be effective for treating many anxiety disorders, too. Other differences may favor particular problems, timing, patient personalities, or the personality of the therapist.
The ABC Model of CBT
Many forms of CBT propose that mental health problems are largely about two things: unhealthy feelings and maladaptive behaviors. Those two big ticket items are obviously related to other issues like toxic or lacking interpersonal relationships and poor physical health. But most CBT therapists focus on helping their clients change feelings and behaviors in ways that will reduce suffering and increase satisfaction with life.
How does a CBT therapist do this?
The simple version proposed by CBT therapists is that we come into contact with stressful events in life (Activating Events), we then have thoughts (Beliefs) about these events, about ourselves, and about the world, that lead to feelings (Consequence–feeling), which set the stage for certain behaviors (Consequence–behavior). This is the A-B-C model.
Here is an example: I am standing at a podium speaking to a bunch of therapists at a CBT conference and I notice a number of them yawning (Activating Event). I then become incredibly uncomfortable and anxious (Consequence–feeling), even sweating from my palms and feeling my heart pound in my chest. The feeling becomes so overwhelming, I begin to stutter, knock over my water glass when I reach for my notes, and end up wrapping up two slides early (Consequence–behavior).
So here we have a stressor (Activating Event), which precedes an intense feeling (Consequence-feeling), which is then followed by behaviors, poor communication and finishing early (Consequence–behavior).
A CBT therapist may ask, me, “If 1,000 people were speaking to that very audience and noticed some people yawning, would they all feel exactly as anxious as you did?” I would likely respond, “Probably not.”
The reason I might give is because of some early incident when I was in fourth grade when a bunch of kids teased me and made me feel inadequate and unlikable. But the CBT therapist would ask, “Ok maybe that is when those feelings started, but what were you telling yourself at the podium in that moment that someone who wasn’t anxious wasn’t telling him or herself—that is what is causing your anxiety now?”
Activating Event x Belief = Consequences
It is not the event alone, but the combination of the “A” and the “B” that produces the “C.”
For the CBT therapist, it is what we are telling ourselves while the stressor is occurring that is responsible for the anxiety now. It may have started a long time ago, but the best way to change it is to find the current thought (Belief) and change it.
By changing the thought, we change the feeling, which makes behaving well a lot easier. When we are anxious, it is so much tougher to speak calmly, to search for the right word, or to fluidly reach over and grab a glass of water and smoothly take a sip before going to the next slide.
What may have caused me to feel like I was about to die? After all the scariest thing in the room was a yawning PhD who probably couldn’t bench press his lunch. It was probably some scary thought like, “Everyone is yawning, they are all bored, I’ll never be asked to speak again at this conference, my career is over, and I’m a failure!”