Cognitive Behavioral Therapy

Today, I think Cognitive Behavioral Therapy, CBT, and Acceptance and Commitment Therapy, ACT should go hand in hand. CBT is more or less the straightforward doing and reasoning regarding behavior and learning. ACT helps with the why, the emotions, and feeling of said emotions and how to observe and reason regarding them – and even though you do have emotions, the concept of ACT tries to help you get going in your valued direction to reach your goals.

Treat with nothing but CBT?

I’ve used this since I started coaching because changing behaviors could be highly relevant to getting a change. Treating with only cognitive behavioral therapy is primarily a good idea if everything else is in order. The coaching is often thorough because it’s absolutely necessary to get satisfied with the results. Having big problems and spending little effort handling them will likely lead to disappointment. So could “trying to solve just a tiny fraction of the big picture”. I’ve met those who’ve been stressed out of their minds and there’s a long list of symptoms, but they want help with one of them. Perhaps the tension headache. When they get that help, they’re rarely satisfied.

The intervention is too small to get a good result. If any. If stress is the perpetuating factor that keeps the headache going, treating “the headache” by looking at the muscles as if there’s nothing else bothering you won’t give any good long-term results. I’ve met those. They have never cheered for their results even if we meet often. The intervention needs to be the right one.

So, I don’t mind doing things with just CBT, as long as I think it’ll work.

What is cognitive behavioral therapy?

Instead of explaining it again, I’ll quote the first part of the chapter “The basics about Behaviors and Cognitive Behavioral Therapy” from the book:

“By getting a decent hunch about the basics of behaviors – why we do them – and CBT, you’ll get the gist of how to change both behaviors and emotions, which is helpful for you to get rid of both unwanted behaviors and unwanted emotions, such as anxiety.

Cognitive behavioral therapy (CBT) generally revolves around changing something that doesn’t work in the desired way and does so by doing to get a tangible change in your behaviors, leading to changes in other areas. It’s either to change the behaviors themselves or to change what they lead to. Behaviors are either done or not, which is binary. We’ll get to why they’re done or not; that is usually analyzed with a “behavior analysis”. Behaviors are also either functional, meaning they lead to what they’re meant to lead to or not. Remember that. Functional behaviors are great. We’d like to get rid of behaviors that are not functional. If they are functional or not depends on the situation. Different behaviors may lead to the same outcome. The same behavior might be functional at different times, so the functionality is a relevant part to keep in mind in the analysis. The context is relevant!

Doing something scary is less likely done and doing something that gives you joy or a pleasant feeling, such as using drugs, is more likely done. That might be obvious, but it’s crucial to underline. The reasoning there is key. We’ll dig deeper into that later. In short – emotions affect what we do quite a lot. Worth mentioning here might be that feelings are affected by external and internal factors, such as things we hear or see or things we think. When I tend to people with CBT, we keep thoughts, emotions, behaviors and physiology in mind. They are all critical. The environment might be relevant as well. To just start by giving a tangible example of how all of this is relevant before we dig deeper into the “how”, let’s look at a tiny part of the start of an analysis of someone’s sleep troubles. When someone can’t sleep, we’ll need to know why, as with every other problem we’re trying to solve. So we do this to try to figure it out:

I tell them:

“How you feel and how you are is a mix of thoughts, emotions, your physiology and behaviors. Are you trying to solve the problematic sleep by changing your physiology when it’s a behavioral problem? Are you too emotional to sleep – but you’re trying to change behaviors? That might not work at all. This is why we’ll look at how to make the issue less abstract.”

And then it’s time to document some things for a few days:

There are four categories mentioned in the previous paragraph, Thoughts, Emotions, Physiology and Behaviors, and you’ll analyze them by answering some simple questions. Write down the answers as curiously and honestly you can. You’re here to explore what’s happening and analyze yourself, not be offended or saddened by criticism of yourself.

So get on with the words!

Write as many answers as you possibly can!

Put the four categories on paper with one in every quadrant and answer:

T, upper left:

What do you think when you can’t sleep?

E, upper right:

What do you feel when you can’t sleep?

P, lower right:

How does your body feel when you can’t sleep?

B, lower left:

What do you do when you can’t sleep?

What did you do the day/evening before you couldn’t sleep that might influence?

This is done because they all matter. One thing affects the other, and we need to change the actual problem, rather than just a symptom. Treating the symptom, such as treating sleeplessness with sleeping pills, generally doesn’t help long term. Before changing what we’re doing, it’s necessary to analyze enough of what we’re doing wrong, so we can change and do something that leads to the progress we want and, in due time, get where we’d like to be. So initially, it’s essential to find the problem or at least find enough of a pattern to change relevant enough things that affect the problem.

That’s mainly done with diaries and questionnaires, like the one above, but could also be done with an interview verbally or through text as long as the questions give good enough answers. We’re looking for a pattern and a chain of events to see what happens when, how much and so on. The result will be an analysis of the problem that is concrete enough to deduce what has to change, rather than just “I can’t sleep” when tending to sleep or “I think and get anxiety” when being bothered by thoughts. An analysis like that ought to include the problem, when it occurs, how it started, and we’d love if we could deduce why it keeps bothering you from the information.

Why it keeps bothering you is likely connected to some behavior(s), which is why we’re going to change just that, behaviors. Behaviors are something you control, so it’s possible to do something about it. It’s likely interesting to know why they’re there and what purpose they’ve got, but as long as they’re changed, that’s what matters most. The changing of behaviors should include you learning what consequences behaviors get. Doing A results in B, and doing X results in Z. If you’ve never reflected about it earlier but rather just… done things and “can’t sleep” or “get anxiety”, that’s likely a helpful lesson to keep doing the right thing. That part is called “applied behavior analysis”; it helps us point out consequences from behaviors and include if they reinforce or punish you for doing what you’re doing. As mentioned before, and as we’ll dig deeper into further down – if you do something and get punished it’s less likely you’ll do it again. If you’re rewarded because something is pleasant – or “reinforced” it’s more likely that you’ll do it again. To keep to sleep and anxiety as the subject, taking a pill to aid sleep or get rid of anxiety is pleasant and, therefore, more likely that you’ll keep doing it.”

Cognitive behavioral therapy — The foundation is practically to question why A leads to B – and then find a way to apply that knowledge and relearn, if whatever it is bothers you.

I don’t treat everything with CBT.

It’s used for plenty of things today. I use it primarily to help people:

Battle Insomnia

Or combat anxiety

… when they’re driving

… from needles

… from ruminating and brooding

… and in social situations.

Depression – but when this is the case, I use more tools than just CBT, depending on how you look at it. If changing everything and looking at your entire life is CBT, then that’s how I prefer to treat depression.