Cognitive Behavioural Therapy (CBT) has long been considered the “gold standard” for treatment of major depression and anxiety (Tsang, Siu & Lloyd, 2011). More recently, CBT has been demonstrated to be effective as an adjunct treatment for schizophrenia, bipolar disease, and chronic pain (Tsang, Siu & Lloyd, 2011; Morley, Eccelston & Williams, 1998).
CBT is the process of looking at the connection between thinking, feeling, behaviour and physiological symptoms/reactions and how they influence one another. Through this process, CBT intervention aims to analyze maladaptive thinking patterns and behaviours, and to restructure them into more adaptive ones.
The Four Component model provides a visual representation of how we can understand the multidirectional influence of our thoughts, emotions, behaviours and physical reactions.
For example, using the Four Component model displayed above, let’s explore the thought of, “Nobody likes me”. This thought may have started in a certain situation, for example, the individual was at a party and people did not talk to him/her. The thought of “nobody likes me”, could influence how that individual feels, behaves and his/her physical reactions to a situation.
He/she may feel depressed (EMOTION) and as a result, he/she may avoid going out (BEHAVIOUR) in social situations. He/she may also feel aches and pains (PHYSICAL REACTION) that are common with depression, which may cause an individual to think he/she are sick and should be staying at home and resting.
As we can see from the above example, the cycle of avoiding social situations is perpetuated not only by the thought “Nobody likes me”, but also through the individual’s emotional and physical reactions.
Being able to break down our reaction to a situation into thoughts, feelings and behaviour can be quite a daunting task. This is why CBT involves the use of Thought Records (see below).
Thought Records help the client and therapist break down the client’s reactions to a specific situation following a structured format.
It further builds on the Four-Component model and asks the client to provide evidence against and evidence for their “Hot Thought” which is their most emotionally charged thought in that situation.
By using a Thought Record, the client and therapist can begin to analyze what thoughts contribute to the client’s negative feelings or behaviours. This also provides the client with an opportunity to view the situation in a different or more accurate way. In CBT, we call this different viewpoint a “balanced thought.”
For example, a balanced thought for “Nobody likes me” might be, “Not everyone likes me, but I have two good friends who do.”
After writing down the balanced thought, the client is asked to rate how believable the balanced thought is to them. This is key in restructuring negative thinking patterns, because if the client does not believe it, then changes in his/her thoughts, behaviours and emotions will likely not occur.
Using the above example, shifting from thinking that “Nobody likes me” to “Not everyone likes me, but I have two good friends who do,” can influence the client’s emotions, behaviour and physical reaction especially if the client finds the statement to be believable.
After coming to the conclusion, “Not everyone likes me, but I have two good friends who do” the client might feel less depressed afterwards and be more willing to go out in social settings with his/her two friends.
If the client does not find it believable, then the therapist and client may need to look at creating a new balanced thought or re-examine the evidence.
Balanced thoughts are not supposed to be merely a positive twist on the situation, but a combination of the evidence for and evidence against the “hot thought.” Clients will find balanced thoughts more believable if they are grounded in evidence, not in sheer optimism.
By learning more about how our thoughts, emotions and physical reactions influence our behavior, the therapist and client can then begin to work on changing maladaptive behaviours. In the example above “Nobody likes me” this thought could be disconfirmed if the client’s thought were proved incorrect in a social setting.
Helping the client come up with small activity experiments is a key component in CBT. We can think all we want, but at the end of the day our evidence for or against our negative/positive thoughts comes from our experiences.
Creating activity experiments begins by looking at the overall goal of CBT intervention and breaking it down into smaller goals. The client and therapist work together to create a “just right” challenge for the client in the form of an experiment. These experiments allow the client to “test” whether their thought is true/untrue.
For example, a small experiment using the above scenario for the client could be, “Call my friend Mary.”
While the client and therapist create small experiments they also look at potential challenges and strategies to help them overcome them.
Referring to the above situation if the client is unable to reach Mary, he/she may feel that it is true, nobody likes him/her. However, if the therapist and client make a plan for him/her to call his/her friend Ben in case Mary is not around, he/she may learn that Ben likes him/her and is able to do something with him/her.
Given the effectiveness that CBT has demonstrated in the literature, it can be a worthwhile treatment to explore with a therapist trained in this intervention. At GLA, we have social workers, occupational therapists, and rehabilitation support workers trained in the use of CBT. Psychotherapy is within the OT scope of practice.
For other health professionals wishing to broaden their understanding of CBT; courses are offered through OISE at the University of Toronto or in 1-2 day workshops.
Written by: Kelly Hunt, MSc. OT, Registered Occupational Therapist