"Grant me the serenity to accept the things I cannot change,
Courage to change the things I can,
And wisdom to know the difference."
Serenity Prayer, Reinhold Niebuhr, 1944
Chapter 1
Psychology of Change
The question of what you can change and what you cannot is vital to your success in therapy and in life. You will learn that there are things you can do to lessen suffering and improve your sense of well-being. This may mean following a program to change something about yourself, but many times it will mean learning how to value things about yourself that you simply can't change.
The kind of change people want for themselves may vary. If you want biological change, we might talk about medicine or drugs. For psychological change, we would talk about emotions and cognitions. For social change, we would talk about the relationships in our lives. We're also going to consider cognitive behavior therapy (CBT), and we're going to look at the underlying theories to tell us how CBT works. We're going to present a specific sets of skills to facilitate change when it's possible. Ultimately, you can become your own CBT therapist with the tools that you learn. But it takes practice, and it takes commitment.
You might think that things like social skills are easy to change. You can change your relationships, or you can try to change your beliefs. But we know that things like introversion and extroversion are very difficult to change, and they very much affect our capacity to learn and to use social skills. You can certainly end a relation-ship, but you may recreate the same relationship dynamics with another person.
In terms of our personal beliefs, it's really is not so easy to make a change. Personal beliefs aren't just an internal process. There are external factors that contribute to what we believe. But remember that even if you can't change an actual event or belief, you might be able to change the way you think about it or react to it.
We are all biological beings. So when we talk about changing ourselves, we're talking about changing our brains. And these changes may trigger changes in others in complex ways. It is helpful to use the bio-psychosocial Venn diagram to understand this process. There is one circle for the biological, one circle for the social, and one circle for the psychological.
Some factors might reside in just one circle, some may reside in two circles, and some might reside in the center to include the biological, psychological, and social factors. If we think about cognitive behavior therapy, the psychological circle comes to mind, since we are talking about our emotions and cognitions. Cognitions are the mental activities that we have: thoughts, beliefs, memories. Behaviors are things that you do by yourself or in a social context.
Cognitions and behaviors are connected to each other. This means that the way you think affects the behavioral choices that you make. Furthermore, the way you think affects the emotions that you have. But it works in the other direction, too. If you start off feeling fairly anxious, you will have anxious thoughts. So the way you feel affects the way you think. The way you feel is going to affect your behavioral choices.
You can flip it around with your behaviors. If you decide that you are going to call your mother, that's a behavior that might influence your mood. You might have an uncomfortable conversation about something that happened a few years ago, and you'll feel anxious afterwards. This will influence your thoughts. So all of these factors are interconnected.
Just as our brains can be trained to improve cognitive func- tioning, we can also train our brains to manage our emotions and interpersonal skills. A study published by Goldapple (2014) indicated that significant hippocampus changes occurred in the brains of patients who were treated with CBT psychotherapy.
Social interactions with a therapist or with each others have the power to change how particular areas of the brain are activated, and this may cause beneficial effects. But it's really hard to reach in and change emotions. It appears that nonspecific factors, like therapeutic alliance and empathy, provide a corrective emotional experience that initiates the rewiring of the brain.
Cognitive behavior therapy gives you the benefit of learning new ways to manage your emotions by changing your behaviors and your thoughts. The CBT therapist wants to understand your thought processes and see if they can be utilized more effectively. If these processes can become more productive for you, it's going to help you emotionally. Likewise, the CBT therapist wants to change your behaviors so you have more satisfying interpersonal relationships. If a therapist can change your behavioral responses, it might help you emotionally live a better life. That's the goal.
Features of CBT
Cognitive behavior therapy is empirical. It's research-based, and it's a collaborative effort between the therapist and the client. We come up with a hypothesis (or idea) as to what is causing the client to feel anxiety, depression, or anger. Then, we test out that hypothesis in the real world, usually by giving homework assign-ments. If our hypothesis is correct, we know what to work on. If it is not, we'll figure out what might have been happening, and we'll come up with another hypothesis and test it out.
CBT is also symptom focused. There is often a number of different symptom measures for depression or for anxiety. We'll get a baseline, then reassess that person over time as they are using the skills to see if the symptoms are improving.
Additionally, CBT is focused on the present. So we won't be sitting a person down and saying, "Tell me all about your child-hood." We might talk about the past if it's relevant to treatment, but we're going to start with where you are now, how you feel now, and what's happening in your life right now. We start with everyday events, and then work our way to an understanding of the individ-ual's personality and relationship dynamics.
Another feature of CBT is that it is time limited. There is an end point. It varies depending on the person, but usually ranges between 12 and 24 sessions depending on what the treatment goals might be. And CBT is skills focused. There is no magic involved. You're going to be taught the individual skills that you can practice in the real world. Then, you will hone those skills through continued practice until you feel that they have been mastered.
History and Theory
Aaron Beck is considered to be the father of cognitive behavior therapy. He was a psychiatrist who found that psychoanalysis was a treatment with no objective goals and no timeframe. Outcomes were poor, and his patients were not improving. This lead to a paradigm shift amongst a group of mental health professionals.
In 1979, Aaron Beck wrote the classic book that opened up the field of cognitive behavior therapy, particularly in terms of depression: Cognitive Therapy of Depression. Beck looked at three key variables: cognition, emotion, and behavior. First, he wanted to gather data about his client's life in terms of the three variables. He called this step detection. Second, Beck wanted to analyze and evaluate the data: Why was the person thinking and feeling depressed? What were the contextual factors? Was this an on-going pattern? He called this step analysis. Lastly, Beck wanted to challenge or even change his client's unproductive cognitions and behaviors. He called this step challenge.
Classic psychoanalysis has a bottom-up perspective. It involves looking at the unconscious desires, beliefs, and wishes of the indiv-idual and trying to bring them up to the surface. Alternately, cognitive behavior therapy starts at the top, with everyday events that are happening, and will sink down until the client has achieved his or her goals.
The difference with CBT is that the goals are up front and transparent. Once an individual has achieved his or her goals, he or she will no longer be depressed or anxious. The client has been able to reestablish a new social support network.
The CBT therapist will want to create what's called a case formulation with the client. This is when we put together all of the data so we have an explanation of why the client's life happens to be the way it is. For the sake of collaboration between the therapist and client, it's going to be important for us to set some concrete goals.
We'll be using questionnaires, looking for potential symptoms of psychopathology. We'll be determining if the client is having trouble functioning as usual in a work setting or in a social setting. We want to get a sense of the timeline: When did the problem start? How has the individual progressed over time? We want to be very concrete and to get specific examples from the client.
One of the advantages of assessment is that we get a clear indication of a starting point, or a baseline of where we are right now. We can reassess that over time as a way to judge progress. This tends to be an objective and reliable way to proceed, and it's key to getting feedback in order to decide whether or not our treatment interventions are working. If they're not working, we will change them.
Cognitive behavior therapists may use surveys, questionnaires, diaries, or semi-structured interviews. These days, therapists also use phone...
