Cognitive Behavioral Therapy Approach
August 7, 2013
Cognitive behavioral therapy (CBT) is a modality that uses a variety of techniques designed to train the client to recognize and correct their faulty family transactional patterns and automatic thoughts. CBT is a widely studied approach that has been found to be effective in treating a variety of disorders in a family or couple setting that incorporates the family as a support system. CBT is a theory that supports biblical principles by giving the clients free choice and easily incorporated with a Christian perspective to offer hope, grace and comfort. Religious imagery, prayer, the Holy Spirit, prayer, scripture memorization and biblical principles are tools available for the Christian therapist to help the client remain true to their personal beliefs and to keep their spiritual systems in place.
Cognitive Behavioral Therapy Approach
Cognitive Behavioral Therapy (CBT) acknowledges that a person’s beliefs, automatic thoughts and beliefs affect behavior. Freedom of choice and personal responsibility are incorporated into CBT which allows the therapist and clients to create a collaborative relationship where they can work together to improve the clients life.
Psychologists Aaron Beck and Albert Ellis are two leading figures of Cognitive behavioral therapy (CBT) (Goldberg, & Goldberg, 2013). In the late 1970’s they began combining behavioral and cognitive therapy techniques to help couples overcome obstacles in their marriage. Albert Ellis posited the A-B-B theory of dysfunctional behavior which states the activating events of a person’s life are not responsible for the unwelcome consequences; instead the irrational and unrealistic interpretations and beliefs are causing the problem.
The CBT is an empirically based modality based on scientific methods that can be evaluated and tested for its effectiveness (Goldberg, & Goldberg, 2013) and is a way for the client and therapist to work together to develop a solution to the client’s problem. According to Asmundson, Beck and Hoffman (2013), “A number of studies from the field of neuroscience support the notion that changes in cognitions and conscious self-regulation of emotions directly influence the electrochemical dynamics in the brain” (p. 203) making CBT a great way to implement second-order changes.
Therapists who practice from a CBT modality believe that emotions influence how individuals perceive certain events and situations(Asmundson, Beck, & Hofmann, 2013). Therapists attempt to help clients by changing how they perceive events and their emotional responses to those events. CBT replaces cognitive distortions and maladaptive thoughts to increase a client’s coping ability and reduce emotional distress through a series of techniques designed to implement second-order changes. CBT has been found to be effective people of all ages in a great many different disorders, including, substance abuse, marriage counseling, depression, anxiety disorders, bipolar disorder, many medical disorders, eating disorders and schizophrenia.
CBT draws its techniques from cognitive therapy and behavioral therapy. Restructuring negative schemas, faulty thought processes, cognitive distortions are an important part of CBT techniques. A CBT therapy session follows “signature session structure including mood check-ins, homework review, agenda setting, homework assignment, and eliciting feedback” (Friedberg, p. 160). The goal of CBT is not to eradicate or standardize the client’s emotions but to activate the client’s abilities to create a more realistic assessment of the situation.
Cognitive behavioral therapy is a collaborative relationship and the perception of the client’s therapist relationship is a contributing factor in the success of therapy (Leahy, 2008). Developing a collaborative relationship with a client is more than saying hello and having a good handshake. To create a relationship with the client the therapist must be an active listener, caring and empathetic without being condescending or judgmental, validating the client creating an environment where the client feels safe and secure. When the client feels safe, cared for and respected,he may open up easier and be more forthright and honest.
A major component of CBT is challenging negative schemas. Schemas are moderately established cognitive structures containing a person’s fundamental beliefs (Goldberg, & Goldberg, 2013). A person’s schema is constructed by experiences, beliefs, and attitudes. Murray Bowen posited that negative schemas often happen early in life may be caused by negative intergenerational transaction patterns causing faulty schemas that need to be reevaluated (Dattilio, 2006). One tool used to challenge faulty or negative schemas is to assign homework to the client.
Assigning homework that builds self-reliance and self-esteem assist the client by creating a sense of empowerment (Dattilio, 2006). Homework assignments can include reading books or articles, activity scheduling, thought recording, behavioral tasks, and bibliotherapy.
|Situation||Taking a test|
|Patients Automatic Thoughts||I’m going to flunk the test|
|Evidence Supporting Automatic Thought||I flunked the last test|
|Evidence that Counters the Automatic Thought||I’ve studied hard and passed every other test|
|Action Plan||Study each night for two hours before bed|
|Time to Begin||Tonight|
|Potential Obstacles||I cannot study when my house is dirty because I get distracted. My dog needs to go for a walk.|
|Strategies to Overcome||Clean the kitchen each morning before work. Take the dog for a walk as soon as I get home from work.|
|Progress Report||August 1: Kitchen was dirty and dog was hyper so I couldn’t concentrate on my studiesAugust 2: Cleaned house before work. Took dog for walk after work and was able to study.August 3: Cleaned house before work but didn’t take the dog for a walk. I put her outside and was able to study.|
While homework is a useful tool, it may not be appropriate for all clients. Before assigning homework the therapist must evaluate the persons reading and writing abilities, level of stress, home environment and cognitive functioning levels. For example, a single parent may find it difficult to complete tasks because she is overcommitted or a child who reads at a first grade level should not be given a book written for adults.
Oftentimes, when a person is anxious or upset their automatic thoughts are inaccurate and unreliable. Self-instruction involves correcting automatic thoughts and cognitive distortions. Correcting automatic thoughts involve teaching the client to recognize faulty thought process and to consciously change those thoughts (Friedberg, 2006). For example, when he thinks “I’m worthless.” the client will stop and tell himself “I am perfect and wonderfully made.” Family members are encouraged to help each other test“…automatic thoughts in the presence of other family members so they support each other’s restructuring efforts” (Friedberg, 2006, p. 162).
Behavioral enactment in CBT is used to uncover maladaptive patterns and to help the family or couple recognize what they are unconsciously doing. Before beginning the therapist needs to learn how the family or couple functions as a family. Next the therapist creates a task for the couple or family to complete that will allow her to see how the family interacts. The task could be playing a new game together, building something or completing a craft. The task needs to include “giving instructions, following directions, receiving feedback, and frustration tolerance. The task should be entertaining, moderately difficult, and result in some desired outcome” (Friedberg, 2006, p. 164). By observing the interactional transaction pattern the therapist is able to see beyond what has been verbally communicated and can witness the family in action allowing her to identify faulty patterns the clients may not be aware of.
In rational analysis clients are asked to draw or act out what the conflict is that they are experiencing. According to Friedberg (2006), each person is asked to create something using shapes, colors and words that represent the conflict and to then explain it. Therapists can also use the empty chair technique and have the clients to place the problem in the empty chair and address it. These activities help the clients collect previous unknown data and to make judgments based on the new information.
Cognitive behavioral therapy is different than other methodologies in many ways. First, CBT encourages families and couples to attend sessions together. Working with families creates unique situations that the therapist must consider before working with couples or families. For example, the therapist must carefully design the informed consent process to include ways to inform children and teens of their rights (Corey, Corey, &Callanan, 2011). In individual therapy, each person comes with his or her own plan. A parent may want their child fixed and the teen may think her parents are the problem. In CBT the therapist is able to see how the family functions and can correct faulty family transactional patterns that may be causing the child to act out. The CBT therapist focuses on the entire units’ thoughts, feelings, behaviors and emotions while an individual therapist concentrates on one person and doesn’t consider the whole unit (Friedberg, 2006).
Studies have proved that CBT in conjunction with antidepressants to be as effective as psychodynamic and interpersonal therapy in managing severe and chronic depression (Rupke, Blecke, &Renfrow, 2006, p. 84). For chronically depressed patients that do not respond to pharmaceutical treatment, studies have shown CBT to be ansuccessful form of treatment (Mitte, 2005). CBT techniques are more effective than traditional cognitive therapies especially positive reinforcement, scheduling enjoyable outings with others, and homework. These tasks have proven to improve relapse rates (Rupke, Blecke, &Renfrow, 2006, p. 84).
There is a vast amount of research on CBT therapy and not all agree on which type of therapy is the best approach. Tolin (2010) conducted “a meta-analysis evaluating the effectiveness of CBT and found that brieferCBT appears to be superior to briefer alternative psychotherapies, andlonger CBT appears to be superior to longer alternative psychotherapies” (p. 719). Another study analyzed 13 different studies and found that CBT “fails to provide corroborative evidence for the conjecture that CBT is superior to bona ﬁde non-CBT treatments” (Baardseth, Goldberg, Pace, Wislocki, Frost, Siddiqui, &Wampold, 2013, p. 395)
In a 1990 study 79% of clients stated that religion was vital part of their lives compared to 29% of mental health workers. However the American Psychologists Association did not incorporate religion into their standards until 1992 (Hawkins, Siang-Yang, &Turk,1999). Therapist practicing CBT from a Christian perspective can easily modify their techniques to incorporate a Christian perspective. One study found religious patients who used religious imagery to be more effective than nonreligious patients who did not use religious imagery (Hathaway, & Tan, 2009).
When working with clients, viewing them as spiritual beings in need of a redeemer who can heal their brokenness is a large part of treating the whole person. While it is possible to treat people without addressing their spirituality, being able to approach their problems from a Christian perspective is extremely helpful. According to Heslop (2008), people are multifaceted organisms that are made up of biological, psychological, and social factors. A persons spiritual self and psychological self, work together and addressing both will allow the person to feel “purposeful and fullfilled” (Hawkins, Siang-Yang, & Turk, 1999). The spiritual self is part of the whole system which incorporates the physical body, cognitive functioning, emotions, and morals. Separating these systems causes part of the whole to not be evaluated causing the whole person to not be healed. The symptoms may disappear and the behavior may change but they are suppressed and not truly healed.
Psalms 107:10, 12-14 says “Some of you were prisoners suffering deepest darkness and bound by chains, you were worn out from working like slaves, and no one came to help. You were in serious trouble, but you prayed to the Lord and he rescued you. He brought you out of the deepest darkness and broke your chains” (Contemporary English Version). This passage of scripture is the best description of my worldview. We are all broken and suffering and the Lord loves us enough to come down and rescue us. He can break our chains of bondage and set us free and give us unspeakable joy.
Psalms 1:2-3 says “they find joy in obeying the law of the Lord, and they study it day and night, they are like trees that grow beside a stream, that bear fruit at the right time, and whose leaves do not dry up. They succeed in everything they do” (New King James Version). The Bible gives us great insight on how to help people and if we study his word, pray and fast the Lord will show us how to use his teachings and to apply them within our practice. CBT therapists can employee scripture memory and religious imagery to help clients change their automatic thoughts. For example, when a client finds themselves thinking “Nothing good ever happens to me. There’s no use even trying” the client can be instructed to repeat Jeremiah 29:11 “‘For I know the plans I have for you’, says the Lord ‘they are plans for good and not for disaster, to give you a future and a hope’”.
Many modalities do not address a client’s family of origin or family transactional patterns. Many times our family of origin is rife with past sins that affect our children. How our grandparents interacted with our parents and their interaction with us dictates how we interact with our children. While most people try to be better parents than their parents were with them, we may not realize our home life was not a healthy environment and we are passing the same dysfunctional attributes to our children. For example, parents often discipline their children in the same manner they were disciplined. The parents may not realizing that slapping your child in the face is not an appropriate way to discipline and could be causing the child emotional harm. To overcome these family transactional patterns we must strive to understand them.
To make a way for the Lord to heal emotional wounds, I personally believe that family transactional patterns and a person’s family of origin need to be explored, understood, and talked about. Creating genograms that analyze family curses such as alcoholism, co-dependency, procrastination, anger and violence, helps clients to physically see their faulty transactional patterns thus allowing them to begin to develop coping strategies that will bring about second order changes.
Christian therapists practicing from a CBT view can utilize Petersen, Sweeten, &Geverdt(1990) adaptation to Ellis’s A-B-C analytical technique. The rational self analysis(RSA) technique allows clients to write their automatic thoughts down and to critically analyze them for negative behaviors and transactional patterns which cause them to behave in self-defeating ways. The primary difference between Ellis’s A-B-C analytical technique and the RSA technique is the client creates a written record of how they want to feel after a certain situation and strives to complete the tasks. The table below has been adapted from Petersen, Sweeten, &Geverdts(1990) Rational Christian Thinking: Renewing the Mind.
|A: Activating Event (my perception)My boss said I did a great job on my presentation today.||B: Beliefs (underlying beliefs that effected my perception)I usually do a bad job and he’s normally unhappy with my presentations.||C: Consequential Feelings (How did I feel after the interaction?)I’m worthless and good at nothing||D: Decisive Behaviors(How did I respond?)Replied by asking if he was firing me.|
|I: “Camera Check” (Objective Perspective Check)My boss stopped me in the hall, placed his hand on my shoulder and said “You did a great job on your presentation. Keep up the good work!” He did not say my other presentations were poorly prepared.||II: Desired Beliefs(How can I modify my beliefs to avoid negative feelings?)“I am wonderfully and perfectly made”“My boss is proud of me”“He sees how hard I’m working and may give me a raise”||III: Desired Feelings (How would I prefer to feel if this event happened again?)Excited and proud of a job well done.||IV: Desired Behavior(How should I behave next time?)Say thank you instead of asking if he was firing me.|
Providing therapy to lost, broken and hurting people is an awesome responsibility and the possibility of making a mistake is great. However, if therapists practice within their scope of competency and apply approved techniques, pray, fast and study then the possibility of lives being healed are even greater than the risks. Cognitive behavioral therapy is an empirically studied approach that provides realistic and approaches that address the person’s psychological, social and emotional being. When a CBT therapist incorporates Christ into their practice they provide the missing piece to the puzzle giving the client access for a complete healing.
CBT provides many tools that align with a Biblical perspective. Assessing transactional patterns, correcting negative or faulty automatic thoughts, utilizing homework assignments, behavioral enactments, RSA and other CBT techniques allows the therapist to enable the client to bring about change by giving concrete and discernible behaviors they can identify and change. Each of these techniques are biblically sound and if used correctly can lead the client towards a healthier life, better relationships with friends and family members and closer walk with the Lord.
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