What is Cognitive Behavioral Therapy (CBT)?

The Underlying Theory

Cognitive behavioral therapy is partially based on the premise that emotions cannot be changed simply by talking about them. Instead, our emotions are a result of our thought, our behaviors, our biology, and our interaction with our environment (family, friends, co-workers, our jobs, culture, living conditions, etc.). Only by changing the way that we think and act can change the way we feel. Our thoughts have a lot to do with why we act the way we do, as well as how we feel. And our behaviors have a significant impact on both our emotions and our environment (for example, how the people in our lives treat us).

The Method

Cognitive Behavioral Therapy (CBT) is a combination of cognitive therapy and behavior therapy.  The primary goal of cognitive therapy is to change self-defeating thought processes so that they are more accurate and so that they lead to more adaptive behaviors and emotions.  The primary intervention is socratic questioning which is designed to help clients learn to think more logically about the way that they see, for example, themselves, their environment, their future and the actions of others.  Cognitions are viewed as the driving force behind emotions (and many behaviors), which thus makes them, and not emotions, the target of intervention.  

Behavior therapy has two potential focuses, depending on the client: behavior change and conditioning.  Interventions for behavior change include identifying factors that motivate maladaptive behaviors as well as barriers to adaptive behaviors; helping clients actively engage in adaptive behaviors by making them easier, by removing barriers and through detailed education about how those behaviors will likely be helpful.  Conditioning, which is particularly relevant to anxiety (e.g., GAD, Panic) and anxiety-related disorders (e.g., OCD), is typically treated with exposure and by teaching clients adaptive ways to NOT avoid anxiety-inducing stimuli so that they can become habituated to anxiety.   

A scientific approach to therapy

Aside from it’s empirically-derived foundation and the empirical support that it has achieved, CBT is also scientific in the way that it is practiced.  Cognitive behavioral therapist think of therapy as a form of “collaborative empiricism,” in that it involves a series of both thought experiments and real-world behavioral experiments where clients learn to think more accurately and adaptively, as opposed to a common tendency to “catastrophize” (blowing things out of proportion – anxiety) or think in black and white terms (“no one loves me” – depression).  We also work with clients to extinguish conditioned fear responses, including panic, avoidance and reassurance-seeking; and to encourage adaptive behaviors such as exercise, finding employment and making and engaging with friends.  We practice the scientific method by constantly monitoring the effectiveness of our interventions, learning from them, and changing them as needed.

Engineering solutions

Empirically Supported Treatments (ESTs) are more tailored forms of CBT that target specific conditions and are sometimes referred to as “technologies.”  They are based on the premise that specific symptoms or symptom clusters are generated and maintained by a specific set of biological, behavioral, cognitive, social and environmental factors.  If those factors can be explicitly understood, they can each be targeted with a specific set of empirically derived and supported interventions, which are packaged together as “technologies.” Thus, cognitive behavioral therapists can be seen as curious, supportive, empathic engineers.  We figure out what is not working, and we use specific tools to fix it.  It is then the client’s responsibility to carry out that plan between sessions and after terminating therapy.

When clients just want to be listened to, we do that.  When they just need support, we do that as well.  But when they want to see their problems go away, we have very good tools to help, and we can sometimes solve those problems or at least alleviate them to the point that the client can be happy.

Client education

Psychoeducation is the bedrock of cognitive behavioral therapy.  Therapy involves teaching clients how to recognize thoughts and behaviors that maintain or escalate their problems; as well as patterns of thinking and behaving that have the potential to alleviate or solve those problems.  In order for that to happen, clients must not only clearly understand maintaining factors and adaptive responses, but also why and how they work so that they are motivated to use them and so that they can use them flexibly in novel situations. 

Our Philosophy

Our approach to therapy is much more than just talk.  It focuses on making your life better in the most effective, efficient way possible.  It is based on the most current research, it makes sense to our clients, and it is always designed to fit each person’s personal strengths, needs, and resources.  Read more below, and for information about sessions and fees, visit the Frequently Asked Questions page.  For information about about your specific needs, go to the menu bar above.

 

Don’t think that you are going to see a “shrink.”  You will not lay down on a couch. We will not overly focus on your childhood or try to interpret your dreams.  We will not just sit and stare at you. And we will not keep asking you “how does that make you feel?”

Therapy begins with a thorough assessment of the problems that you are experiencing so that we can determine which treatment approach is most likely to work.  We want to be able to help you better understand what is going on and what we need to do in order to make it better.  We will then work together to form a structured treatment plan that is based on the most current scientific findings. We will carry that plan out in subsequent sessions, and you will be asked to practice certain skills at home between sessions.  Techniques include, among other things, education, practicing behaviors, problem solving, gradual exposure to fears at a pace that you are comfortable with, and learning to more accurately interpret others’ intentions.

We are not experts in medication, and we are not licensed to administer it. There is also overwhelming evidence that CBT is a significantly better option for the treatment of anxiety and OCD, and is equal to (and significantly) more long-lasting than medication for depression.

Our Philosophy:

You always have control

You should never be left in the dark.  What happens in therapy should always make sense to you, and you should always be informed so that you can make your own decisions about treatment, and you should be given control of it.  You should be informed of your condition, what causes and maintains it, how to fix it, and why.  If anything does not make sense to you, it should be clarified.

Increasing the good while reducing the bad

While almost all of our clients come to us because they are facing a problem in their lives such as stress, anxiety or relationship problems, it is important to remember that reducing problems is only part of what must be done.  One of the first things that we do when working with clients is to help them identify areas in their lives that can be enriched through fun, connection with others, or self-fulfilment.  And then we help them find ways to pursue these goals.

We use only the best approaches

Only the most proven, most current, and most appropriate approaches should be used.  Specific approaches should be used for specific problems, and they should be administered by a psychologist or a counselor who understands and knows how to administer them properly.  Clients should be given choice and power to make their own decisions about therapy.  Therapy should never take longer than it needs to, and it should fit the specific needs and strengths of the client.  And if treatment isn’t working after an appropriate amount of time, it should be altered to give the client a better chance of getting better faster.  You can read more about our approach at the following links: Anxiety, Stress, Marriage and Couples, Low Sexual Desire

Our work focuses on the whole person

It is not enough to focus only on one’s thoughts and feelings.  If we try to understand problems in overly simplistic ways, they are often more difficult to solve. Problems with our emotions, our thinking patterns and our relationships cannot be properly solved without a holistic understanding of the biological, the psychological, and the social aspects of the person.

  • Biology: Biological issues such as hormone imbalances, medication side-effects, smoking, fatigue from problems sleeping, and diseases such as diabetes can have a dramatic effect on emotional well-being, intellectual functioning and memory, and relationships with other people.  We typically refer our clients to a physician for a medical evaluation in order to ensure that a given problem is not at least partially medical in nature and so that we have a full understanding of medical problems that the person might be suffering from.
  • Psychology: An ability to think flexibly about routine daily problems, to see safety in a safe situation, and to see the good even in people you don’t like can make you physically healthier, while making your relationships with family and friends stronger and more rewarding.  But it c an also go the other way.  Mental processes such as worry, a tendency to jump to conclusions or to blow things out of proportion, or overly negative views of one’s self or others can have dramatic effects on physical well-being and on relationships with others.
  • Social Relationships: Extensive scientific studies have demonstrated that positive and rewarding relationships can have a positive (and sometimes curative) effect on both psychological and medical problems.  On the other hand, relationship problems can drastically increase both physical and mental stress and lead to physical and mental disorders, which in return can have a negative effect on relationships, creating a self-perpetuating cycle.  Thus, social relationships are almost always a significant focus of our practice, assuming that is what a given client wants.
  • Lifestyle change: We also help our clients to find better ways of living a healthier lifestyle, which can have a dramatic effect on the mental well-being of any person, including reducing the severity of depression and panic attacks, as well as overall stress levels.  But because lifestyle change is hard, our skills are often necessary to help our clients find easier and more effective ways of motivating themselves toward positive change.

Your childhood might be an important topic of conversation

Past iterations of this webpage have led some of our clients to state “I know you don’t want to talk about my childhood, but…” This is not the case. Sometimes  a person’s childhood and adolescence is the central cause of their current plight, or it has at least set off a chain reaction that led them to where they are. If this is the case, we as providers need to know. In some cases, talking about childhood an adolescence can lead to solutions. But there are other cases where some therapists are so obsessed with the importance of childhood that they will try to force their clients to believe that it is the root of the problem when it is not.

For example, if you were raised by basically good parents, in a basically stable environment, and you ended up pinned under a truck in Afghanistan after an IED killed some of your friends, we are not going to assume that you have PTSD because your father worked too much and didn’t play catch with you. And we are not going to try to dig up or create a “repressed memory” just to prove our point that it must have come from childhood.

So if you think that childhood is an issue, tell us. We need to know. We can did into it as much as we need to. If you don’t think your childhood is an issue, briefly tell us anyway. Just in case. Either way, in the end, we will mostly talk about what you can do in the here-and-now to make your life better.

What we do not do

There are a number of unsubstantiated practices and myths that many or most mental health practitioners adhere to.  Some of them are not harmful per se, but they can lead to you wasting your time and missing out on opportunities to get better faster.  Some of them can be quite harmful.  We take your trust in us very seriously and we go to a lot of effort to stay educated in the best ways to help you.  But we also take great care to not to engage in any of the practices below.

Falling asleep:  It has come to our attention that a few therapists in the Charlottesville area are known for falling asleep while in session with clients.  This will never happen when you have an engaged therapist who is actively working to help you.  It is well known that many therapists just sit and listen while their clients talk.  This often leaves people not only feeling that they are not being listened to, but it also leaves them feeling as if they are not actually receiving help.  This kind of behavior from therapists is sometimes well-intentioned, even if it is completely counter to what we know about what makes an effective therapist.  But if a therapist genuinely doesn’t care, they can be prone to drifting off and daydreaming while their clients talk, which sometimes leads to them falling asleep.  We find this extremely unethical, and we will not do it.  We will always work with you and we will always be engaged.

Recovered memories:  There are no such thing as repressed or recovered memories.  When a person is severely traumatized, more often than not, they try to forget about the trauma and cannot.  The belief in repressed and recovered memories goes back to unsubstantiated theory from the early 1900’s and has been debunked many times in research.  There have been many cases in which therapists have suggested that clients have been, for example, molested as a child when they have no recollection of such an event.  In many of these cases, clients have developed Posttraumatic Stress Disorder (PTSD) or depression without even having experienced a trauma.  It is a quack practice, and it should never be used.

Over-focus on childhood:  Sometimes your childhood is relevant to your problem.  Sometimes it’s not.  Research clearly demonstrates that too many therapists needlessly waste clients’ time focusing and putting too much emphasis on childhood when it’s not relevant.  The treatments that we use all recognize the effect that childhood has on any given person, but also recognize that many things that have happened to you since your childhood hold equal relevance and are sometimes even more important.  We will ask you about your childhood.  But therapy will focus, except in rare cases, on the present or the last few years.  If we are working on marital problems, of course we will talk about the beginnings of your relationship as well as previous ones. 

Dream interpretation:  Sometimes dreams occur because you have something specific on your mind.  Sometimes they are a random combination of TV shows and conversations that you had during the day.  Sometimes nightmares occur because you are afraid of that particular nightmare occurring.  There is no set meaning for a particular dream and we will not pretend that we have a secret formula for interpreting them.  Dream interpretation can sometimes be fun.  But we are professionals, and we won’t play carnival games with your health.

If you have any questions about other practices that concern you, please do not hesitate to ask us and we will address them here.

Evidence-Based Therapy

Evidence-Based Therapy

We recognize that the field of mental health has a justifiable reputation for being unscientific and ineffective.  Researchers estimate that between 250 and 500 different mental health treatment approaches have been developed, but only 4 of them have received any credible empirical support at all for a range of disorders.

One of these approaches has a very strong scientific basis and can be profoundly helpful if that scientific knowledge is used and evidence-based guidelines are adhered to.  Cognitive Behavioral Therapy (CBT) and more condition-specific cognitive behavioral treatments (e.g., EX/RP for OCD and Behavior Activation for depression) have been shown in numerous randomized controlled trials and Meta-analyses to be superior to not only placebo, but to supportive therapy (i.e., generic “talk therapy”) and psychodynamic therapies (e.g., therapies that focus on discussing one’s childhood and supposed unconscious processes).  Cognitive Behavioral Therapy has been shown to effectively treat the following problems, among others. In the case of most of these problems, the scientific support for CBT over other approaches is overwhelming to the point that many leading researchers and policymakers believe that the debate has been settled, at least until new approaches are developed.

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