What is CBT?
“We cannot solve our problems with the same thinking we used when we created them”
Cognitive Behaviour Therapy (CBT) can help people who are experiencing a wide range of difficulties including anxiety, depression, OCD & panic. CBT supposes hat what people think can affect how they feel and how they behave. This is the basis of CBT.
During times of emotional distress, people think differently about themselves and what happens to them. Thoughts can become extreme and unhelpful. This can worsen how a person feels. They may then behave in a way that prolongs their distress.
CBT practitioners help each person identify and change their extreme thinking and unhelpful behaviour. In doing this, the result is often a major improvement in how a person feels and lives.
Cognitive and behavioural psychotherapies are a range of therapies based on concepts and principles derived from psychological models of human emotion and behaviour.
Theoretical Perspective of CBT
The term ‘Cognitive-Behavioural Therapy’ (CBT) is variously used to refer to behaviour therapy, cognitive therapy, and to therapy based on a combination of principles of behavioural and cognitive theories.
What to expect from Cognitive Behaviour Therapy (CBT)
Slightly differently to psychotherapeutic counselling, which takes a more active listening, non directive approach, your CBT therapist is likely to take a didactic, or teaching approach, to help you to identify the links between your thoughts, feelings and behaviour. The aim of this ultimately being that you will learn the skills to become your own therapist, and can apply these skills to other situations. You will establish a ‘problem hierarchy’ meaning that we will collaboratively establish the priority of issues that CBT will focus upon. CBT will also require you to undertake tasks between sessions, for instance, once you have understood the basic principles, you may be asked to keep a diary so that the content of your thoughts in certain situations can be identified. You will be taught how to ‘evidence base or challenge’ the content of these thoughts, in order to reduce your distress.
There may also be situations you are avoiding due to how you are feeling, these will also be discussed with you, and you may be taught some anxiety management techniques in order to help you to begin to expose yourself to situations that you are avoiding, (this is called ‘situational exposure’). There will be an agenda for each session, which will begin with the progress of between-session activity. The idea of engaging in thought challenging, and situational exposure is that your anxiety will reduce, and that your life will open up again, thus leading to an increase in your mood, and an improvement in your overall wellbeing.
Intensive CBT (usually more than 8 sessions) will involve your therapist offering you a ‘formulation’ of how your difficulties have developed, and will seek to address more deep seated, core beliefs and cycles of behaviour. Once you have challenged these beliefs, it is hoped that you will experience enduring release from long standing distress.
Trauma focused CBT
If you have experienced traumatic events or experiences, you will be offered an adapted form of CBT - called Trauma Focused CBT. You will learn more about psychological trauma on the ‘life’s difficulties’ pages, but essentially trauma-focused CBT teaches you about the nature of trauma, helps you to develop relaxation strategies, and then helps you to process the traumatic memories through narration, imagery, and creative or other methods. Your therapist will work with you at an individual level you to find out the best ways for you to process these traumatic memories and help you to change your beliefs about your experiences. Trauma focused CBT sessions usually require a minimum of 12-18 therapy sessions.
Trauma-focused CBT should only be delivered by a suitably qualified and experienced CBT therapist who has undertaken additional training in psychological trauma.
What is Dialectical Behaviour Therapy (DBT)?
DBT is a model of therapy that is very similar to CBT, and has been developed to help individuals who struggle on a day to day basis with managing their emotional states. When having these difficulties, individuals may utilise strategies that are unhelpful to them and others. These may include self harming behaviour, suicidal intentions and actions, lashing out and/or rejecting others, and other impulsive behaviours such as over-spending, over-eating, drinking, taking drugs, gambling and promiscuous activity, to name but a few.
Due to having difficulties in controlling emotions & behaviours, relationships can be difficult to maintain, and those seeking to help can be rejected. Individuals who experience these difficulties spanning across their early adult & adult years often attract the psychiatric diagnostic label of “Borderline Personality Disorder, or Emotionally Unstable Personality Disorder’. This can often be an unhelpful diagnosis, as it can lead to ‘professionals’ judging behaviours, and not fully understanding the overwhelming struggles of the individual underneath.
Dr Marsha Lineman is an American psychologist whodeveloped DBT. Her perspective on those with a diagnosis of ‘borderline or emotionally unstable personality disorder’ is that individuals are actually suffering from ‘emotional regulation disorder’, and this inability to regulate emotions often lies in traumatic early experiences, particularly in relation to inattentive, neglectful, and/or abusive primary care-givers. That, as children, these individuals have not been taught, or experienced how to regulate the primary emotions of anger, disgust, fear, happiness, sadness and surprise (shock).
An inability to regulate these primary emotions leads to them becoming overwhelming and then an unhelpful action will be performed (eg self harm, lashing out, etc) to get rid of the emotion, which unfortunately leads to unwanted secondary emotions, such as guilt and shame, and of course the consequences of the unhelpful action that has been taken.
DBT recognises that whilst individuals engage in behaviours that are unhelpful to themselves and others (eg self harming, suicidal, impulsive and risky behaviours are called “Life Threatening Behaviours”), that the individual is doing the best they can, with the resources that they have got. DBT encourages individuals to consider their life goals in terms of having “A Life Worth Living”.
DBT identifies four areas that individuals who struggle to manage their emotions have not had any help with:
Core Mindfulness, being able to make ‘wise mind’ decisions, rather than take impulsive actions
DBT proposes that having a therapist who respects the individual, and can teach them the core skills that have been missing in their early years, will encourage the individual to value their own life by reducing their “Life Threatening Behaviours’” and work towards “A Life Worth Living”.
What does Dialectical mean?
The word “dialectical” describes the notion that two opposing ideas can be true at the same time. In DBT, there is always more than one way to think about a situation, and all people have something unique and different to offer. Dialectics allows for a balance between acceptance and change, both of which are necessary for establishing a fulfilling life.
What this means is that a DBT therapist accepts clients as they are by understanding that engaging in unhelpful behaviours is the client’s way of solving a problem (emotional distress) while also acknowledging that they need to change in order to reach their life goals, and have “A Life Worth Living”.
The Behavioural element of DBT means that your therapist will primarily offer strategies with the deliberate intention of rewarding your learning and use of helpful behaviours, and reducing your Life Threatening Behaviours.
What does DBT involve?
The absolute primary target of DBT is to keep the client alive - as described earlier, many individuals experience repeated and intensive urges to harm themselves or end their lives, as an unhelpful strategy to manage their distress. Therefore, if you are engaging in DBT, the first thing your therapist will ask of you is to commit to the first treatment goal of reducing “Life Threatening Behaviours”. You will also be expected to complete diary cards on a weekly basis.
You initially enter the “Pre-Treatment’ Phase, which typically involves:
Orientation to the DBT model
Use of diary cards
Introduction to the core skills
Strengthening your commitment to reducing “Life Threatening Behaviours”
Therapist & Client working together on producing a written agreement. (This is re-visited at 6 months, or if commitment wanes).
Once you have made this commitment, and developed a crisis plan with your therapist, your therapist will then begin to teach you the core skills of: emotion regulation, distress tolerance, interpersonal effectiveness and core mindfulness. This is very much a teaching approach, and you will have ‘homework’ activities and things to practice between sessions, which includes the completion of diary cards which are reviewed at the beginning of each session.
If you are receiving DBT in a residential or specialist NHS setting, you may be offered a ‘full DBT programme'. This will involve weekly sessions with an individual therapist, and also weekly group meetings.
If you are engaging with DBT with a private therapist, it is likely that you will receive DBT-informed therapy, as you may not have access to the weekly group meetings.
DBT is considered a long-term therapy, and you will be asked to commit to a year long DBT programme. This will involve weekly sessions of therapy, with a review at 6 months.
How will I work on early trauma, if it is identified?
One of the sad and unfortunate consequences of using life threatening behaviours to manage emotional distress that has been caused by early traumatic experience is that it can make accessing trauma therapy difficult. This is because it is necessary in trauma-focused therapy for you to process the trauma by being exposed to thinking about it and describing it, in the comforting presence of your therapist. Understandably, for those who find it difficult to manage difficult emotions and distress, engagement in trauma therapy can lead to an escalation in self harming and suicidal behaviours, thus making trauma therapy too risky. Sometimes, what is called ‘chronic’ or ‘complex’ PTSD can develop.
One of the benefits of engaging with DBT is that you will learn to tolerate and manage your distress, reduce your life threatening behaviours, and improve your quality of life. Once you have achieved this, the third (and I believe) essential target of DBT is the resolution of early trauma. This will involve you engaging in a form of trauma focused therapy in order to work through early traumas. Upon completion of this stage, you should be well on your journey to A Life Worth Living.
Why choose Nicola at Nine Wellbeing as my DBT therapist
Nicola is a fully qualified DBT therapist, having undertaken the intensive DBT programme in 2012. Nicola has previously spent many years working in specialist NHS Eating Disorder and Personality Disorder settings delivering full DBT programmes, and is highly experienced in working with these presentations. Nicola is a warm and sensitive therapist who values the unique person behind their experience, and as a qualified trauma therapist is passionately committed to working with you to reduce the impact of relational trauma.
Please note that if you engage in individual DBT therapy with Nicola, you will be receiving DBT-informed therapy, as there will be no group component to your DBT treatment.
I am interested in finding out more about CBT & DBT with Nicola at Nine Wellbeing. What should I do?
You can make an enquiry via the contact page.
Nicola Forshaw holds a Masters Degree in Counselling (with distinction), a diploma in Cognitive Behavioural Therapy, and a certificate in Dialectical Behaviour Therapy. Nicola is a highly experienced trauma/PTSD therapist and is and is fully qualified in EMDR (Eye Movement Desensitisation and Reprocessing). She is accredited by BACP (British Association of Counselling & Psychotherapy), and is also a registered member.