Cognitive Behavioral Therapy: The Basics

Medical Reviewer

Cognitive Behavioral Therapy is an approach to treatment based around the relationship between thoughts (cognitions) and the behaviors stemming from these. By focusing on particular thoughts and beliefs known to negatively affect mood and behavior the therapist collaborates with the client in order to alleviate the problem(s). In this Sharepost I'll look at panic episodes as an example. The intention of therapy is to reveal how beliefs, thinking errors and coping strategies work together in a kind of vicious circle and to find alternative ways of coping.

Cognitive behavioral therapy (CBT) is based around the four general principles of education, restructuring the way the person thinks, exposure to feared situations or events and relapse prevention. The first step however is a detailed assessment and profile of the individual and their unique issues.

An important component of CBT is education. The role of the therapist is to explain how a perceived threat causes their client to feel anxious and how this quickly moves towards the thoughts and sensations associated with (in this example) panic. The client will often be able to give a detailed account of the safety behaviors they use in the lead up to a panic event. Safety behaviors are the things people do to make themselves feel less anxious and more secure, for example avoiding certain situations or  drinking alcohol to boost confidence.

The therapist works with the client in order to develop an understanding of the beliefs and thought processes active in the lead up to and actual panic event. As part of this process the therapist may use a series of small experiments such as word associations (e.g. dizzy-fainting) which tend to elicit a mild state of anxiety. The therapist uses this to point out how thoughts and physical sensations are linked.

Fear of fainting is a common problem in people who experience panic. This is one example where the therapist is able to both educate and challenge the belief structure of their client. For fainting to occur, blood pressure has to fall, but in the case of anxiety blood pressure increases. This neatly illustrates how beliefs can be contradicted by evidence and the feared catastrophe cannot actually occur through the process of anxiety.

Education is helpful but it is usually insufficient to fully modify the catastrophic thought processes that accompany panic. A more successful method is through the use of behavioral experiments. The most common of these is called hyperventilation provocation. Here, the client is asked to stand up and take several long deep breaths. After a few breaths the client will begin to experience sensations of panic (tingling in extremities, dizziness, palpitations). This promotes the client to seek out safety behaviors but the therapist will try to encourage them to continue with the exercise in order to demonstrate their fear is based on belief rather than what will actually happen. Not only will the client not collapse, faint or fall over, but they can be asked to engage in behaviors they previously considered impossible such as balancing on one leg. The intention of all these tasks is simply to disconfirm often well-entrenched beliefs about what may happen during a panic episode. Hyperventilation tasks will not be undertaken will clients who have physical problems such as asthma or epilepsy.

As therapy draws to a conclusion the therapist will try to identify any outstanding beliefs or indications of safety behaviors still being used that could point towards the possibility of relapse. Top up sessions can also be arranged around 12 weeks after therapy to monitor progress and reaffirm progress.