Open your mind to CBT

Cog­ni­tive Be­havoural Ther­apy or CBT is on ev­ery­one’s lips. And it seems to be chang­ing to com­bine with mind­ful­ness. So where is it go­ing?

The Irish Times - Tuesday - Health - - Health Cbt - Jamie Ball

Epicte­tus hit it on the head. The an­cient Greek philoso­pher noted: “Men are dis­turbed not by things, but by the view which they take of them.” Two mil­len­nia later, there is an ar­ray of psy­cho­log­i­cal tools at our dis­posal to help us trans­form one such view for an­other.

Struc­tured upon decades-old, em­pir­i­cal re­search and psy­chother­apy, cog­ni­tive be­havioural ther­apy (CBT) has come of age. Whereas mind­ful­ness chiefly con­cerns get­ting out of your head by rais­ing aware­ness to the in­ter­nal and ex­ter­nal ex­pe­ri­ences of the present mo­ment, CBT is more about un­der­stand­ing that how we think and feel is not au­to­matic or in­vol­un­tary, nor gov­erned by the unconscious or ge­net­ics, but is a process that can be rad­i­cally changed should we have the will to do so.

While mind­ful­ness can ap­pear at times over the past decade to be in­ac­cu­rately painted as a panacea for most men­tal health prob­lems, it is in fact just one al­ter­na­tive to cog­ni­tive and other talk­ing ther­a­pies.

How­ever, prob­lem-fo­cused and ac­tionori­ented CBT is about re­claim­ing from au­topi­lot the sea of un­help­ful, un­pro­duc­tive and of­ten un­founded thoughts, be­liefs and in­ter­pre­ta­tions (eg mag­ni­fy­ing neg­a­tives and min­imis­ing pos­i­tives, over-gen­er­al­is­ing and “catas­trophis­ing”) that can flood us each day, un­der­stand­ing the con­text from which they have arisen and re­plac­ing them with al­ter­na­tive, more re­al­is­tic and con­struc­tive cog­ni­tions.

CBT al­lows you to iden­tify base­less, ex­ag­ger­ated or ex­treme think­ing, rou­tinely ric­o­chet­ing about your mind, for what it is, while un­der­stand­ing that it re­ally does not have to be this way, un­less you want it to. But only you can make that change.

Trig­gers

It comes down to the trig­ger. Were you ever to come across a dead body in the street that just “hap­pened” to be shot, wouldn’t you want to learn who pulled the trig­ger, when and why?

The re­sult­ing corpses of our way­ward thoughts are sim­i­larly sus­cep­ti­ble to trig­gers, of­ten in­duc­ing un­pleas­ant phys­i­cal symp­toms (eg but­ter­flies in the stom­ach, in­creased heart rate or body tem­per­a­ture) or spurring ten­u­ous de­ci­sion-mak­ing and re­gret­table be­hav­iour – of­ten all in the space of sec­onds.

How­ever, we have tra­di­tion­ally paid a neg­li­gi­ble de­gree of time com­pre­hend­ing or ad­dress­ing what those trig­gers are and how they’ve come to be. The fin­ger which pulls the trig­ger is mar­shalled by our core be­liefs and these are spawned, but not set, in child­hood. CBT can en­able us to iden­tify and de­code these be­liefs that sub­lim­i­nally steer our path through each day and our life.

All about the core

“These are our ma­jor be­liefs about our­selves, about our world and about other peo­ple,” says Gal­way-based clin­i­cal psy­chol­o­gist Dr Clare Kam­bamettu.

“Our core be­liefs act like a fil­ter, through which we view ev­ery­thing that hap­pens to us in our lives. They in­form how we think about the world, of­ten de­pend­ing on what hap­pens to us on a daily ba­sis.”

Kam­bamettu says CBT can be used for both gen­eral well­be­ing, as well as treat­ing men­tal health is­sues such as de­pres­sion or anx­i­ety.

“But we also know from re­search that it’s very use­ful in help­ing us build self-es­teem and stress-re­sponse skills, and help­ing us in our day-to-day lives. From my own ex­pe­ri­ence, un­der­stand­ing how my thoughts make me feel and be­have has prob­a­bly been one of the most help­ful skills that I’ve learned through­out my adult life.”

While de­pres­sion and anx­i­ety are known to be treated most ef­fec­tively from CBT, it has also been used to treat – with vary­ing re­sults – stress, worry, pho­bias, panic at­tacks, ob­ses­sive com­pul­sive dis­or­der, eat­ing dis­or­ders, anger, pain and sex­ual dys­func­tion.

De­spite re­cent re­search that sug­gests CBT may not be as ef­fec­tive at it once was deemed to be, Kam­bamettu stresses most sci­en­tific re­search still sup­ports it as one of the most ef­fec­tive in­ter­ven­tions for treat­ing many men­tal health prob­lems.

“CBT has been shown to be more ef­fec­tive in treat­ing is­sues such as anx­i­ety dis­or­ders than tra­di­tional treat­ments. But when it comes to mild to mod­er­ate de­pres­sion, we know it is equiv­a­lent to an­tide­pres­sant med­i­ca­tion, in terms of re­sponse and rates of re­lapse.”

Third­wave

Kam­bamettu, the di­rec­tor of Light­house Clin­i­cal Psy­chol­ogy ser­vice at Gal­way Bay Med­i­cal Cen­tre, says we are cur­rently ex­pe­ri­enc­ing the third wave of CBT, which is stretching into a fourth.

Al­though cog­ni­tive psy­chother­apy has its roots in an­cient phi­los­o­phy, “CBT started in the 1950s in the United King­dom and United States. At that point it was be­havioural ther­apy. Psy­chol­o­gists were learn­ing about the im­pact of be­hav­iours on men­tal health and on our ex­pe­ri­ences of the world.

“Then the sec­ond stage, which was called cog­ni­tive ther­apy, took place from about the late 1960s. This is when peo­ple started to place more em­pha­sis on the pat­terns of our think­ing, in re­la­tion to our be­hav­iour,” she says.

Cog­ni­tive and be­havioural ther­a­pies have merged since the 1980s to be­come cog­ni­tive be­havioural ther­apy. As its tech­niques are rig­or­ously eval­u­ated, ap­ply­ing sci­en­tific ev­i­dence rather than anec­dote, CBT is now mor­ph­ing into its fourth di­men­sion: mind­ful­ness-based CBT (MBCBT).

“Mind­ful­ness on its own has not been proven to be an ef­fec­tive in­ter­ven­tion for de­pres­sion or anx­i­ety but mind­ful­ness-based CBT has been proven to do this,” says Kam­bamettu.

“But given that mind­ful­ness, CBT and mind­ful­ness-based CBT are all the buzz words at the mo­ment, and where a lot of re­search money has been tar­geted, it’s im­por­tant to re­mem­ber that there are many ap­proaches to lots of dif­fer­ent types of prob­lems.”

Biopsy­choso­cial model

Ac­cord­ing to cog­ni­tive psy­chother­a­pist and chair­woman of the CBT sec­tion of the Ir­ish Coun­cil for Psy­chother­apy, Anne Ma-

rie Reynolds, ev­ery­body can ben­e­fit from CBT.

“CBT is based on an in­di­vid­ual as­sess­ment and con­cep­tu­al­i­sa­tion of a per­son’s pre­sent­ing prob­lem. It also uses So­cratic dia­logue to as­sist a per­son in gain­ing in­sights that can fa­cil­i­tate the change process,” says Reynolds, who adds that how we view events is based on be­liefs that have been formed in child­hood and are re­ally im­por­tant in un­der­stand­ing how you are in the world to­day.

Cog­ni­tive psy­chother­apy ad­heres to the biopsy­choso­cial model; dis­ease at­trib­uted to the com­plex, vari­able in­ter­ac­tion of bi­o­log­i­cal, psy­cho­log­i­cal and so­cial fac­tors. In lay­man’s terms: ev­ery­thing is con­nected.

De­pend­ing on the pre­sent­ing prob­lem, CBT can serve as an ef­fec­tive al­ter­na­tive to an­tide­pres­sants, says Reynolds, who lec­tures stu­dents on the cog­ni­tive psy­chother­apy masters course at Trin­ity Col­lege.

“So some­one who is ex­pe­ri­enc­ing sui­ci­dal de­pres­sion, or who is hear­ing voices, will need med­i­ca­tion in con­junc­tion with cog­ni­tive psy­chother­apy. But most anx­i­ety-pre­sent­ing prob­lems can be treated with­out med­i­ca­tion.

“Long term, CBT helps the per­son man­age and un­der­stand the pre­dis­pos­ing fac­tors, so it works at a deeper level.”

Post-trau­matic stress dis­or­der is but one case in point: med­i­ca­tion will help treat some of the symp­toms, but not the un­der­ly­ing trauma of the ex­pe­ri­ence. Sim­i­larly, an an­tide­pres­sant is not likely to change our view of our­selves.

Sep­a­rat­ing fact from fic­tion in the thought­pro­cess

“CBT can be used re­ally ef­fec­tively for di­ag­noses such as al­co­hol treat­ment, drug abuse, de­pres­sion or anx­i­ety,” says coun­sel­lor and psy­chother­a­pist Siob­hán Mur­ray.

“What it wouldn’t be used for would be more clin­i­cal ar­eas, such as bor­der­line per­son­al­ity dis­or­ders.

“It just wouldn’t make enough of an im­pact . . . But as with any treat­ment, some­body has to want to change their be­hav­iour.

“CBT changes the first thought process, ask­ing if that thought is fact or fic­tion. Is it based on some­thing real or some­thing they fear hap­pen­ing, in which case it is not fact.”

But what if you’re just nat­u­rally a glass-half-empty sort of per­son?

“We all need a cer­tain level of anx­i­ety in or­der to mo­ti­vate us to do cer­tain things. But it’s only when those lev­els of anx­i­ety im­pact us, or those around us, on a daily ba­sis that it be­comes an is­sue and needs to be ad­dressed.”

Mur­ray of­fers a six-week CBT pro­gramme, dur­ing which deeper is­sues are some­times re­vealed, to be dealt with in later weeks and months. And to help par­tic­i­pants avoid slip­ping back into their old thought pat­terns af­ter the pro­gramme is fin­ished, Mur­ray asks them to keep a jour­nal.

She also sug­gests that two or three months af­ter the course has fin­ished, par­tic­i­pants should come back for a fi­nal, or near-fi­nal, ses­sion and pos­si­bly again for a fi­nal ses­sion a few months af­ter that, in or­der to check in on the trig­gers that are send­ing one back to old thought pat­terns.

“I bring in a lot of grat­i­tude into CBT. It in­volves daily rep­e­ti­tion. You have pos­si­bly spent 20 years in a thought pat­tern that hasn’t been serv­ing you well, and you are now try­ing to change it in six weeks. It’s about con­tin­ual prac­tise and be­ing con­sis­tently aware of your thought be­hav­iour pat­terns.”

Right, Dr Clare Kam­bamettu, di­rec­tor of Light­house Clin­i­cal Psy­chol­ogy ser­vice at Gal­way Bay Med­i­cal Cen­tre.

Be­fore com­mit­ting to CBT, en­sure your would-be psy­chother­a­pist is suit­ably qual­i­fied, ac­cred­ited and ex­pe­ri­enced. In other words, vet him or her like you would for a wannabe em­ployee.

Just like with some mind­ful­ness fa­cil­i­ta­tors pass­ing them­selves off as “ther­a­pists” across the coun­try, some al­leged “cog­ni­tive psy­chother­a­pists” have no train­ing or ex­pe­ri­ence of work­ing in men­tal health.

“There are a lot of peo­ple who call them­selves cog­ni­tive psy­chother­a­pists who are not ad­e­quately trained or qual­i­fied,” says Anne Marie Reynolds, cog­ni­tive psy­chother­a­pist and chair­woman of the CBT sec­tion of the Ir­ish Coun­cil for Psy­chother­apy.

Qual­i­fi­ca­tions “They should have an un­der­grad­u­ate qual­i­fi­ca­tion in a rel­e­vant, health-re­lated field and a post­grad­u­ate qual­i­fi­ca­tion to mas­ter’s level, which means they have con­tin­ued pro­fes­sional devel­op­ment, on­go­ing clin­i­cal su­per­vi­sion and en­gage in re­flec­tive prac­tice.

“That is cer­tainly not the case for ev­ery­body who pur­ports to be a prac­tis­ing cog­ni­tive psy­chother­a­pist.”

Re­search The first stop for those in­ter­ested in CBT is the web­site of Cog­ni­tive Be­havioural Psy­chother­apy Ire­land (cbti.ie), an ac­cred­i­ta­tion­body­forcog­ni­tive be­havioural psy­chother­apy. It is part of the um­brella body of the Ir­ish Coun­cil for Psy­chother­apy that rep­re­sents more than 1,500 psy­chother­a­pists in the coun­try.

Sim­i­larly, the Ir­ish As­so­ci­a­tion

Ask ques­tions When look­ing for a psy­chother­a­pist, don’t be afraid to ask about his or her back­ground, train­ing and ex­pe­ri­ence, no mat­ter what his or her ther­a­peu­tic modal­ity (eg, psy­cho­an­a­lyt­i­cal, in­te­gra­tive, con­struc­tivist or cog­ni­tive be­havioural psy­chother­a­pist).

How­ever, a cog­ni­tive psy­chother­a­pist is un­ques­tion­ably the best suited pro­fes­sional when it comes to CBT. Like in most pro­fes­sions, one size doesn’t fit all.

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