A form of therapy called Cognitive Behavioral Therapy (CBT) gets mainstream attention because CBT works and widely used. But what is it?
Rex gets angry at having to wait “too long” in lines, being cut off in traffic, for being put on hold, for having to wait at stop lights or even when his children make a mess, aren’t performing as he thinks they should be. He tells anyone that he has a right to be angry. “People make me mad and then they have to deal with me.”
His wife divorced him as she cited the emotional abuse as the reason to leave. He and his girlfriend fight, break up and get back together. His children don’t want to spend time with him and he can’t hold a job as he gets fired due to his anger outbursts. Does Rex sound like someone who would report being happy? Very unlikely.
How can CBT help someone like Rex? Let’s explore.
CBT isn’t one Thing
The term CBT is an umbrella term. It encompasses all the different therapies that have a few tenants at heart. All forms of CBT include:
- Focus on how our thinking is the cause of our emotional states
- Starts with the client’s goals
- Tends to be shorter in duration with noticeable results rather quickly
- Heavy on tools that once learned are life long means to improved emotional states
- Tend to be educational in model and very often has work to be completed outside of therapy sessions
- Relies on a strong relationship between client and therapist but isn’t the mechanism of change
- Less emphasis on diagnosis and more on the treatment of symptoms and client’s goals.
To name a few…
The number of CBT therapies is really unknown. I don’t know of anyone at this point who has put together a list of all the modalities of therapy that utilize CBT. To name a few of the more popular ones – Cognitive Therapy, Rational Emotive Behavioral Therapy, Rational Living Therapy, Cognitive Processing and Mindfulness-Based Cognitive Behavioral Therapy. Other adaptions include substance abuse and different populations such as Matrix Model for Substance Treatment or Dialectic Behavioral Therapy.
This is a drop in the bucket.
A short list as reported on Wikipedia included a list of 37 and that isn’t exhaustive.
What does it mean by CBT therapist?
What does it mean if you see that a therapist in a directory such as Psychology Today or Therapy Tribe that lists CBT as a therapy that they do?
Honestly, it doesn’t mean much. Since it is an umbrella term, you the consumer of therapy services, don’t learn much from such a generic term. It’s like going to a restaurant and saying, “bring me a meal.” The wait staff isn’t going to know what meal that you want.
Ellis and Beck – The Grandfather’s of CBT
Dr. Arron Beck and Dr. Albert Ellis are considered the grandfathers of CBT. Each were working in the 1950’s and expanded upon the idea that it is our thinking that is the cause of emotional responses and that we can change our emotional responses by examining and changing irrational thinking.
Cognitive Therapy
Beck called the therapy that he develop as Cognitive Therapy. He focused on the interpretations or meaning made which he termed cognitions. He also developed schemas or thought patterns. He started with discussing solutions to depression and then later adopted his form to include other mental health issues.
Dr. Aaron and his daughter Judith Beck at Beck Institute
Other Cognitive Models
Beck’s work was a starting point for several other cognitive therapies. One that is quite helpful for trauma work is Cognitive Processing Therapy which explores the current beliefs about trauma, challenges those and then works to replace the belief with a more rational belief about either themselves or the world.
Trauma Focused Cognitive Behavioral Therapy focuses on reducing trauma symptoms for children. TFCBT includes humanistic principles as well as interventions focused at the children and the family system. The therapy originally was for sexual abuse victims and is now used for many forms of childhood trauma.
Rational Emotive Behavioral Therapy
Ellis developed a therapy that is now know as Rational Emotive Behavioral Therapy. He like Beck, focuses on how it is our thinking that creates our emotional landscape. He formalized the therapy to be more systemic, defined ways that we use irrational beliefs and developed a process to dispute and replace those beliefs. Ellis supposed that us human beings have rational thoughts that drive rational decisions and matching responses and irrational thoughts that drive negative states. When we correct irrational beliefs, then we are going to develop more rational emotional states such as joy.
Dr Albert Ellis and his wife Dr. Debbie Joffe Ellis who continues to teach REBT
Rational Behavioral Therapy
A student of Dr. Ellis, Dr. Maultsby developed a form of therapy that was somewhat different than Dr. Ellis. He called it Rational Behavioral Therapy. He wrote a book with that title in 1984 in which he outlined his more systematic approach. He coined the idea of rational self-counseling in which anyone can learn and teach themselves rational skills. He provided the format that people could then follow to achieve the emotional states that they wanted.
He focused on learning therapy and implemented quite a few behavioral techniques into his system. He was influenced by Ellis and also by his medical practice.
Rational Living Therapy
My teacher, Dr. Aldo Pucci, studied first Behavioral Therapy and then under Dr. Maultsby and learned RBT. REBT and RBT were both influences for Dr. Pucci.. Because of his own experiences as a power lifter, he added hypnosis. As he explained, he like Maultsby before him found himself doing RBT differently enough to be it’s own form of therapy.
The development of Rational Living Therapy included: REBT, RBT, Cognitive Therapy, brain functioning, cognitive development theory, social learning, classical conditioning, operant conditioning, linguistics, neurolinguistic programming and hypnotherapy. Therapists aren’t concerned as much about diagnosing but instead focus on the learned thoughts and behaviors that are interfering with the client’s goals.
RLT is a systemic therapy where client’s know where their are in the process of therapy. The addition of hypnosis as a tool for change is unlike most CBT. Hypnotherapy is optional but is one more way to meet a client’s goals.
Pictured is Dr. Aldo Pucci from National Association of Cognitive Behavioral Therapy.
Third Wave
CBT on it’s own is quite powerful but in the third wave creators incorporate mindfulness principles. The first is Dialectical Behavioral Therapy develop by Marsha Linehan which was meant to treat people with so call borderline personalities. She added mindfulness skills in order to stop the client from time traveling to the past or future and work and exist in the here and now.
Other forms include Acceptance and Commitment Therapy which is more about noticing the cognitions and related emotional states vs trying to change them. Then there are mindfulness based therapies such as Mindfulness Integrated Cognitive Behavioral Therapy that incorporates Theravada principles. Another is Mindfulness Based Cognitive Therapy and Mindfulness Stress Reduction which looks at creating new relationships with uncomfortable emotional states.
CBT Based Substance Treatments
CBT has been used very successfully in substance treatment. People in treatment examine the thinking that sustains and promotes use and then replaces those with rational beliefs. One such is Matrix Model for Stimulant Use. It has been in use for over 20 years in intensive outpatient programs. It was for cocaine but is used with a variety of substance addictions.
A self-help group that is based on REBT is SMART Recovery. SMART stands for Self-Management and Recovery Training. It is peer ran group that meets much like 12 step groups. That is the only basic similarity. SMART Recovery developed a 4-Point Program: Building and Maintaining Motivation, Coping with Urges, Managing Thoughts, Feelings, and Behaviors; and Living a Balanced Life.
Does it matter which CBT therapy I use?
What is more important to which form of CBT is the competence of the therapist in that form of CBT. In order to be effective teachers of CBT, the first step is that the therapist actually believe the model of understanding emotional landscape. The basic belief is that it isn’t things that causes our upset but our reactions to those things that happen in our lives.
In a normal healthy brain free from diseases or injury, the thoughts create the emotion. I have supervised therapists who say that they believe that is true and then say things like, “No wonder the clients are upset considering what they went through.” What they went through may be something that many of us do not wish to endure, but it is the meaning made from the events, not the events themselves that cause the problem. If the therapist doesn’t believe this then they are going to be quite confusing.
A red flag in therapy is if a therapist says that they include CBT in the therapy that they do. This is the doughnut box style of therapy. Although it is very nice to have a wide selection of doughnuts, it isn’t helpful when it comes to therapy. These mix and match of styles or what is termed eclectic isn’t replicable or teachable to clients. That means that once therapy is over to maintain the results, one has to go back to therapy.
One criticism of CBT is that the therapist is confrontational and unfeeling. Yes, CBT is rather confrontational. But certainly not unfeeling or therapists lack empathy. Instead CBT therapists must utilize accurate empathy. Since we often speak to the irrational beliefs, we first work to develop trust, understanding and tact.
Applying Rational Living Therapy
Remember Rex from earlier? If Rex went to a RLT therapist, he would first define what it is that he wants from therapy and life – his goals. He would answer if anger and rage were the emotions that he wanted or if there were other emotional experiences that he would like to have regularly.
The therapist would explain how it is our thinking in a healthy brain that is the cause of our emotions. When we have happy thoughts that produces happy emotions and the same could be said for negative thoughts for negative emotions.
Does he want strained relationships with other people and his children? If he said no, the therapist could use that motivation to help him start to challenge the anger provoking thinking.
Learning how to replace irrational beliefs
He may think he has a right to be angry or that people shouldn’t disrespect him or that he needs people to do what they are supposed to which are all irrational thoughts.
Working with Rex, the therapist would help him come to see that although anger is a human emotion there isn’t any one entity that grants any of us the right to anger. In the USA, we have the right to life, liberty and the pursuit of happiness. He may wish people would treat him with respect. He may want it very much, but it is a want and not an absolute need like the air we breathe.
He may come to realize that screaming and yelling at people doesn’t usually motivate others to treat us well. It is fine to wish for people to do what you want, but that we are in control of our actions and not other people.
Over time and with practice, Rex could learn more rational ways to see the problems in his life. When Rex is no longer believing that other people must (musterbating is the term Dr. Ellis coined) do what he wants or that respect isn’t something that one can demand with screaming, and then let go of that want, he is likely to have a very different experience.
He may come to think himself into joy and do so regularly.
Want to learn more?
If you would like to learn more, please look at other articles or my website at Rational Lifestyle Consulting.
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