A Cognitive Behavioral Therapy Primer

You can put the tips in this cognitive behavioral therapy primer to use tomorrow, which will allow you to serve your patients more effectively and allow you to be a much better referrer.

From the outset, recognize that this process can be easy; you just have to a little patience and want to do it.

The etiology of emotion

Belief

When we grow up, we have emotional responses that at their base, are the same as those we make in adulthood. “He made me mad. She made me mad.” What happens, makes us feel.

Truth

"Nothing ‘tis good or bad…thinking makes it so" - Shakespeare

It is what we perceive that makes the emotion. We have very little control over the universe; there’s always something that you can’t control. The power here lies in the fact that if the patient understands where emotion comes from, then you can begin to control them.

The Process

You’re sitting in a bus that is stuck on train tracks, down the line appears a bright white light bearing down on you. You’ve got three seconds to live before you’re vaporized.

What emotions are going through your head? Terror? Panic? Fear? Most likely you’ve terrorized yourself in a split second. But none of that has anything to do with the train.

Meanwhile, a man named Claude sitting next to you says, “Ahhh, free at last.” He is as relaxed as any human being you’ve ever seen. He is an end stage AIDS patient who has been in pain for months.

The thought processes here are entirely different. It’s not about what actually happens, but how we perceive it. Our thoughts about these occurrences create feelings, and these feelings are fine, as long as they’re rational.

Problems begin when things start to get off kilter. A nervous person has thoughts that loop in a negative cycle. In addition to thoughts and feelings, we’ve got actions. Actions also feed into the negative cycle.

Thoughts --> Feelings --> Behavior --> Thoughts --> Feelings --> Behavior and on and on

Physical symptomsThis negative cycle of thoughts, feelings, and behavior, manifest themselves physically in headaches, cramps, diarrhea, and other symptoms, exacerbating an already declining situation. “I’m always going to feel this way,” the patient tells him/herself, and subsequently gives up on everything else, further descending into a negative spiral.

Four basic irrational beliefsSally is at the salon getting her hair and nails done. She thinks she’s going to become the prom queen later that evening. After leaving, she breaks three nails on her steering wheel. “Oh my god, now people are going to think I’m ugly. I can’t go to the prom! Now I’ll never get married, never have a house or kids, no future…I’m just going to drive off this bridge.”

Albert Ellis condensed

  • Perfection --> Failure
  • Love and approval --> Worthlessness
  • Fairness --> Whine, pout, tantrum
  • Punishment --> Depression, anger

Perceptions of four major negative emotions

Sadness = perception of loss

Anger = perception of violation

Fear = perception of threat

Guilt = perception of responsibility

And now we are ready to begin...

Using the information above, you should be able to structure an effective behavior modification program that your patients can use to begin the climb out of their depression. For example, ithe program progression could look like the following:

  1. Exercise at an intensity that is medically safe
  2. Social support - Depressed individuals tend to pull away and withdraw from social circles. Getting them re-engaged with other people helps lift their mood. If, for whatever reason, they cannot turn to family or friends, suggest that they volunteer somewhere, like an animal shelter, nursing home, or day care center.
  3. Activity - Getting an individual with depression to engage in some kind of activity or hobby will help re-establish routines that most likely fell apart at onset of depression. The set schedule will instill a sense of purpose and hopefully lift their mood through enjoyment of the activity.
  4. Read The Feeling Good Handbook by David Burns, MD - Certainly it doesn't have to be this particular work, but having your patient read an authoritative, yet accessible work that focuses on key principles of the program that you have designed for them will foster its acceptance and reinforce the need to commit to it by keeping the idea of behavior modification top of mind.
  5. Regular psychotherapy with a physician or mental health professional

Brief, but effective Techniques

Discuss these techniques with your patients as coping strategies they can use to deal troublesome situations.

Two-column Thought Record

In one column, your patient writes their worst fears about a given situation. After taking some time to relax, they re-evaluate in the second column.

What if everyone hates my talk?

That’s never happened in 20 years of presentations.

I’ll never be invited back.

If it goes badly, it’s unpleasant but not catastrophic.

I’ll be a failure.

My wife and dogs will still love me.

0-100% Mood/Event Rating

This is similar to the two-column thought record, but instead they take an event and put it into context with the events of their life.

  • I am 90% mad about getting this parking ticket.
  • This is nothing compared to my father's death. In the big picture, the ticket is worth a 7% rating.

Tantrum Time

Have your patients schedule time in which they deliberately let out their anger in a safe manner. This is an effective forum through which patients can relieve stress, however, it cannot carry over beyond the designated time.

Often, Tantrum Time will come around and patients have had enough distance between the triggering event and Tantrum Time that they no longer consider it to be that important.

Mood Rating

Have your patient rate their mood regularly (on a negative 10 to positive 10 scale) in order to assess the effectiveness of various aspects of the program; to help them identify patterns in their mood changes; and to help them put their moods in perspective through comparison.

Addictive vs Preferential Words

Review, with your patient, the language that they use. Halt "addictive” thinking by getting the patient to monitor, reduce, and eliminate words (and especially combinations) such as must, should, have to, always, and never, that could trigger an irrational belief.

Always remember: Don’t should on me.

The failures of CBT

Be aware that this program may not work in all cases. The most common reasons for the failure of cognitive behavioral therapy stem from:

  • An unrealistic expectations - Behavior modification takes time and patients can get easily frustrated over having to put in work without the prospect of immediate relief
  • Patients, knowing that they will have to work toward change, rather than more passively take a pill, will often want to wait until they “feel like” working at therapy, which of course, they never will.
  • Quick initial relief - Some patients may respond very well to treatment and mistakenly feel that they are cured. Because of this false sense they stop treatment and end up back where they started.