Psychotherapy

Psychotherapy is the treatment of emotional problems using psychological techniques. Psychotherapy requires a good therapist-patient relationship in which the therapist is seen as caring, understanding, and supportive.

Cognitive Behavioural Therapy

Cognitive Behavioural Therapy (CBT) is a type of psychotherapy based on the idea that our feelings and behaviours are determined by the way we think. In other words, if we think, gloomy thoughts we feel down and depressed and behave in a negative way. Similarly, if we constantly think that something terrible is about to happen we feel anxious, fearful and worried.

In CBT, we learn to identify negative thoughts and to replace them with positive and reasonable thoughts. By recognizing and changing this depressing way of thinking, we learn to feel better about ourselves, others, and the world around us.

The idea that our feelings are controlled by our thoughts is very old. Almost 2000 years ago the Greek philosopher Epictetus laid the groundwork for Cognitive Behavioural Therapy when he wrote "it is not things themselves that disturb men, but their judgments about these things."

 

THOUGHTS

 

FEELINGS

 

BEHAVIOR

Much later, the playwright William Shakespeare noted how our thoughts determine feelings when he wrote "there is nothing either good or bad, but thinking makes it so."  The medical profession was introduced to the cognitive approach to psychotherapy in 1906 when Dr. Paul Dubois, a Swiss neurologist, described the strong links between thoughts, feelings, and behaviours.

Our thoughts determine how we feel and how we behave. Similarly, our feelings and behaviour affects our thoughts. Figure 1 illustrates all the possible connections and feedbacks that can occur.

CBT helps patients to identify and change not only the self-talk characteristic of depression but also the negative self-talk that occurs in anxiety. The cognitive techniques are effective whether the anxiety occurs as part of an anxiety disorder (e.g. generalized anxiety disorder), or as part of a depressive illness.

The ABC's Of Psychotherapy

Albert Ellis was one of the first pioneers of a cognitive (or thinking) approach to treating psychological problems. Cognition is another word for thought and the word cognitive refers to the thoughts that are often unreasonable in psychological disturbances.

Dr. Ellis' approach to therapy can be remembered using the letters:   "a-b-c-d-e"

A stands for the activating event (or adversity) confronting the patient.

B stands for the beliefs (and thoughts) that the patient has about the activating event.

C stands for the emotional consequences that result from the thoughts and beliefs. If the beliefs and thoughts are reasonable and balanced, an appropriate emotional response will follow. If however, the beliefs and thoughts about the activating event are distorted or unreasonable, the patient will feel sad, anxious, or depressed.  For example, if one believes that perfection must always be attained, a score of 75% on a school test may lead to disappointment, sadness and anxiety.

D stands for disputing (or challenging) the unreasonable beliefs and thoughts.

E stands for the effective outcome (i.e. feeling happier and less upset).

Progress can be monitored by using a form identifying (A) activating events, (B) beliefs and thoughts, (C) consequences, (D) disputing techniques, and (E) effective new outcomes

When activating events occur we usually have thoughts that occur like a reflex. These reflex thoughts occur because of deeper beliefs.

Unhealthy Self-Talk

People upset themselves by developing the habit of viewing things in a negative and unreasonable manner. The phrase BAD MOODS identifies the destructive types of self-talk that make people feel depressed and anxious.

B   Black and white thinking

A   "Awfulizing"

D   Discounting the positives

M   Maximizing the negatives

O   Overgeneralization

O   Overestimating likelihood of negative outcome

D   Demanding

S    Self-blame

Black and White Thinking is the tendency to look at things in extreme (all or nothing) terms. Things are either completely good (white) or completely bad (black), instead of recognizing all the shades of grey in between. The patient fails to understand that both good and bad qualities are present in many events and people.  There is no balanced view and words such as "always" or "never" are used.  Black and white thinking not only occurs in depression but also leads to anxiety when the patient sees situations as completely safe of completely unsafe, finding it difficult to accept uncertainty.

"Awfulizing," a term introduced by Ellis, is the labelling of things as awful or terrible. Rather than accept disappointments as unfortunate, uncomfortable and frustrating, each event is reacted to as if it is a catastrophe.

Discounting the Positives & Maximizing the Negatives occur when positive and good events are ignored or minimized while the negative aspects of an event are exaggerated and focused upon.

In Overgeneralization a small negative event is allowed to darken one's outlook completely like a drop of ink in a glass of water.

Overestimating the likelihood of a negative outcome occurs when the patient predicts that the worst possible outcome imaginable will occur. This type of self-talk is often found in anxiety disorders when the patient constantly worries that everything will go wrong and that life will turn out badly.

Demanding is the use of the words should and must to describe what is expected of oneself and others. "I must not fail." "Others should treat me fairly."  "My circumstances must be positive".  Therapy aims at changing the inappropriate demands to more reasonable preferences and desires.

Self-Blame occurs when one is self-critical and unfairly blames oneself for something bad that has happened.

Having recorded beliefs and thoughts on the ABCDE exercise form, the phrase BAD MOODS is then used to identify underlying patterns of negative self-talk. For example, do the recorded beliefs and thoughts suggest that there is overgeneralization? Are the recorded beliefs and thoughts based on the conviction that everything will turn out awful? Do the recorded beliefs and thoughts focus on negative factors with discounting of positive events in the environment?

Having identified the destructive inner dialogue, therapy helps replace negative self-talk with a more balanced and reasonable assessment of oneself and one's situation.

Just as our thoughts and feelings determine our behaviour, our behaviour also affects the way we think and feel. If day after day is spent lying in bed or moping around the house, a person will eventually think that he or she is useless and wasting life away. This type of thinking results in feelings of sadness and depression.

A Balanced Life

There are 6 Life Zones which need attending to (Figure 6). When there are problems or deficits in one zone a person feels "out of sorts." Becoming aware of and nurturing all 6 Life Zones will leave a person less disturbed when a loss occurs in one particular area. When John lost his job, his work Life Zone was dealt a big blow. However, because John had balanced his life by having developed all 6 Life Zones he tolerated the job-loss quite well.

 

Six Life Zones (each a piece of the pie – "v", making a round circle).

(1)          v  Health

(2)          v  Relationships

(3)          v  Work

(4)          v  Money

(5)          v  Leisure

(6)          v  Personal Growth

 

The Role of Medication

In depression and anxiety, the aim of therapy is complete removal of all symptoms and full recovery of function in every area of life. Although cognitive behavioural strategies alone are sometimes effective, antidepressant medication is often needed. Several studies have shown that the best results may be obtained when treatment includes both psychological and pharma-cological strategies.