Understanding Cognitive Behavioral Therapy

A closer look at a take on “talk therapy."



illustration by emma moreman

Sigmund Freud is reputed to have said, “Sometimes a cigar is just a cigar.”

We don’t know about that, but there’s no denying that of all the various approaches to mental health therapy, cognitive behavioral therapy (CBT) has become one of the most popular, with ample research demonstrating its effectiveness as a treatment for a range of problems, from anxiety and depression to marital trouble.

“CBT is a success story in psychotherapy — I would say more so than any other type of intervention both in terms of the practical application of it and in terms of its research,” says Robert E. Brady, PhD, director of the Anxiety Disorders Service at Dartmouth-Hitchcock, and assistant professor of psychiatry at the Geisel School of Medicine, Dartmouth.

Unlike Freud’s psychoanalytic model, CBT does not focus on the past so much as it probes a person’s day-to-day thinking habits. “CBT is a method that helps patients to identify thoughts and beliefs that are inaccurate, maladaptive, and have adverse consequences on mood and behavior,” says Michael R. Kandle, PsyD, a licensed psychologist in Durham.

“It’s really about helping clients understand the interconnection between their thinking, their emotions and their behaviors,” says Andrew Gersten, PhD, a licensed psychologist in Manchester.

Some CBT providers use the approach as an intervention for a wide spectrum of mental health conditions, Kandle says, but others “do not believe that CBT is the be-all-and-end-all type of therapy for most conditions.”

Research provides clearest support for CBT’s effectiveness in treating anxiety disorders and depression, as well as obsessive-compulsive and trauma disorders. “Those are the clinical problems that it’s had the strongest effect for,” Brady says.

One of the primary goals of CBT is self-management. Patients learn and apply techniques and skills that help them evaluate their problematic thinking styles and maladaptive behaviors, and manage their emotional problems. “I tell folks oftentimes that I’m helping them to become their own therapist,” Brady says. “My role is to guide the change that they’re looking to see, and to teach them a way of doing that for themselves, even after the therapy is done.”

The number of CBT sessions a person will need depends on the individual and the concern that brought him or her to therapy. Some patients might require only four or five sessions, while others might need to receive treatment for a couple of years, Gersten says. Regardless, the focus during CBT is on helping the patient recognize the influence that thoughts have on emotions and behavior, and correcting distorted thoughts and beliefs.

It seems likely that most of us will have at least a few of those. “Especially by the time we’ve become adults,” Gersten says, “we’ve developed defenses … that help us to avoid experiencing emotions.” But defense mechanisms, such as denial or intellectualizing rather than allowing ourselves to truly experience feeling, can lead to trouble in the long run

CBT, like other forms of mental health therapy, can discomfort patients as it requires them to confront their troubles, and work to overcome habitual responses. “You’re asking someone to change really ingrained, longstanding patterns of belief — and that’s challenging for people,” says Brady. “But what most of my patients would say is, that challenge was certainly worth the outcome.”


Understanding exposure therapy, a form of CBT

If you suffer from a phobia or other anxiety-provoking condition, you might not like the sound of exposure therapy. After all, just about no one wants to come face-to-face with something that causes them distress.

But exposure therapy calls on us to do just that — albeit gradually. It is based on the premise that we naturally avoid objects and situations that distress us, and in doing so often worsen the anxiety associated with those objects or situations. Exposure therapy works by helping patients to gradually and safely confront a troubling source of anxiety, and break the cycle of fear and avoidance. It is often employed by cognitive-behavioral practitioners, and is commonly used to address phobias, panic disorder, obsessive-compulsive disorder and post-traumatic stress disorder.

Exposure therapy is not about force. Rather, it encourages patients to take baby steps that eventually add up to a big result. A patient who is acutely afraid to fly, for example, might begin by simply looking at pictures of planes, or going to an airport to watch planes take off.

“It helps a person to recognize the relative low risk of whatever it is they’re avoiding, and to make a decision to accept that little bit of risk so they can live a better life,” says Robert E. Brady, PhD, director of the Anxiety Disorders Service at Dartmouth-Hitchcock, and assistant professor of psychiatry at the Geisel School of Medicine, Dartmouth. “And in turn, what we see is a gradual decrease of fear and anxiety related to the experience and whatever that thing or situation is.”

Through exposure therapy, Brady says, cognitive behavioral therapists act as guiding hands that help patients “approach the thing that they’ve been dreading or avoiding — sometimes for over a lifetime.”

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