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What is Comprehensive Cognitive – Behavioral Therapy?
How is CCBT used to Overcome
Social Anxiety Disorder?
Thomas A. Richards, Ph.D., Psychologist
Director, Social Anxiety Institute
It wasn’t long ago that very few people had heard the term "cognitive - behavioral therapy".
With the outpouring of research in the 1980s, and the studies on anxiety disorders that were published in the 1990s, the term "cognitive – behavioral therapy", or CBT, gained acceptance and became well known. But even though the term itself became well known, just what "cognitive- behavioral therapy" involved was less well understood.
Meanwhile, in study after study, cognitive – behavioral therapy began to prove to be the therapy of choice for many mental health care problems, including depression and the anxiety disorders.
In fact, large-scale, long-range (i.e., longitudinal) studies over the past decade have consistently shown cognitive – behavioral therapy to be the only therapy that can be dependably relied upon to help people overcome clinical anxiety disorders.
While this was good news, some rather large questions continued to cloud the horizon. For example, each study defined CBT in a different way, and most studies were rather vague in their explanation of just what CBT was considered to be. The other big problem was that people began to think of cognitive-behavioral therapy as a "unified" therapy, or as a therapy that was "set" or always the same for every mental health care problem
In fact, CBT is a combination or a "pulling together" of any and all methods, strategies, and techniques that work to help people successfully overcome their particular emotional problems. The cognitive part of the therapy refers to thinking or learning and is the part of therapy that can be "taught" to the person. The person then needs to take what has been taught, practice it at home, and through means of repetition, get that new "learning" down into the brain over and over again.
This is essentially the same process as school or college learning. You are taught some new information or skills, and then you learn them. When you learn them well enough (through repetition), this affects your memory processes (and physiologically your brain’s neural pathways) and allows you to begin thinking, acting, and feeling differently. This takes persistence, practice, and patience, but when a person sticks with this therapy, and does not give up, noticeable progress begins to occur.
The behavioral component of CBT involves participation in an active, structured therapy group, consisting of people with clinical social anxiety. In the behavioral group, people voluntarily engage in practical activities that are mildly anxiety-causing, and proceed in a flexible, steady, scheduled manner. By moving forward in this manner, step by step, and through the use of repetition, the anxiety felt in social situations is gradually reduced. The behavioral therapy group should consist of people with social anxiety only. People with other emotional problems should not be mixed into this group. Even an "anxiety" group will not work. Because the problems are very different from each anxiety disorder to the other, the behavioral group and its activities would prove to be ineffective for people with panic, generalized anxiety, or obsessive-compulsive disorder, even though these are clinical anxiety disorders as well.
At the same time, the social anxiety behavioral group builds confidence and produces a more rational perception in the persons’ mind concerning their own abilities and competencies. The behavioral group must be structured in a step-by-step hierarchical fashion, and should include consistent cognitive reminders before and after people actively work on their specific, individualized anxiety hierarchies.
Thus, the cognitive-behavioral therapy we do for social anxiety does not contain the same information or proceed in the same manner as cognitive-behavioral therapy for other mental health care problems.
For example, CBT for depression is very different in nature than CBT for social anxiety. Because the problem is different, CBT for social anxiety contains different methods and strategies than CBT for depression, panic disorder or generalized anxiety disorder. Thus, cognitive-behavioral therapy, while always being active, structured, and solution-focused, must employ different ways of overcoming the particular emotional problem in question.
CBT is not a "set of methods" that work for all disorders. There are not simply two, three, or four strategies that work to help everyone with all kinds of mental health care problems.
Thus, the specifics or details of CBT are not universally applicable. This has been a thorny issue for professionals who do not really understand what cognitive-behavioral therapy involves. With the advent of managed care, the insurance companies now want therapists who say they can do "cognitive-behavioral" or "solution-focused" therapy. So, in order to be included in these groups and panels, professionals now will usually say they do "cognitive-behavioral therapy". But what exactly does this mean?
At this point in time, almost every licensed therapist knows the accepted terminology. The question becomes do they understand CBT and can they do it? This is only the first relevant question and the first hurdle to cross.
The second issue the professional must understand and must be able to accomplish concerns their ability to use specific CBT methods and strategies to help people with a particular disorder, such as social anxiety. When specific cognitive-behavioral therapy for social anxiety is not understood or put into place, then people with social anxiety disorder will not receive the help and assistance they need to overcome this debilitating anxiety disorder.
Because each mental health care problem is different, and because people with social anxiety disorder respond to different CBT methods, strategies, and approaches, the professional should be cognizant of how to lead, guide, and help people with social anxiety overcome this specific anxiety disorder.
I receive dozens of e-mails and other correspondence each day, with one of the recurring themes being, "I went through cognitive-behavioral therapy and I didn't get any better. What’s wrong?"
The answer to this question is another question: "Did you receive appropriate, comprehensive cognitive therapy and appropriate, comprehensive behavioral therapy, and were the cognitive and the behavioral components of the therapy "reinforced together" in your mind by your therapist?
This, of course, leads to the question: "What exactly is comprehensive cognitive – behavioral therapy, and how does it differ from traditional cognitive behavioral therapy?"
The traditional answer to "what is cognitive-behavioral therapy" has been "restructuring" the mind (i.e., thought processes) by means of disputing irrational thoughts and beliefs and substituting rational thoughts and beliefs in their place. There is usually mention of breathing exercises and relaxation techniques as well.
"Cognitive restructuring" or "learning to think rationally" are essential components of cognitive therapy for social anxiety disorder. However, while learning to notice and eradicate automatic negative thinking (and slowly moving the thinking up to automatic rational thinking) is essential for overcoming social anxiety, there are fifteen to twenty specific steps that need to be learned to be able to do this. You cannot tell a person with social anxiety to simply stop thinking negative thoughts. Obviously, the person does not want to think negatively, and if they could choose to stop thinking negatively, they would do so in a heartbeat.
We must employ very specific ways to allow the person to begin to (a) catch their own automatic negative thinking, (b) find distractions to use while therapy is in progress, and (c) begin to turn the tables on automatic negative thinking gradually. The mind will not accept "irrational positive" statements or beliefs. Repeating "I will wake up in the morning and be happy, content, and less anxious" will do absolutely nothing, because this statement is irrational, given the current state of the mind. Therefore, emphasizing positive thinking and giving out positive thinking statements to people with social anxiety disorder is going to be ineffective, and will only prove to the person that the therapist does not understand and does not know how to successfully treat social anxiety.
The mind cannot work overnight and cannot be pressured into learning things faster. So, it is important, in the cognitive process, to turn the tables on automatic negative thinking slowly. To do this, people with social anxiety learn to catch their automatic negative thoughts and then make them rationally neutral. As they find this process easier, they begin to catch more of their automatic negative thinking. This, in turn, leads to consciously turning this negative thinking into rational neutral thinking. Then, this neutral thinking is gradually moved up, always in a step-by-step manner, to a more realistic level, so that with time and repetition, the person’s thinking moves slowly upward and becomes more realistic. At first, this is a conscious process, but the more it is practiced and repeated, the more it becomes an automatic process.
Now, to get even more specific, how do we accomplish these cognitive goals? We use a series of printed handouts that accompany the office visits. The role of the therapist is to know what to do and at what pace therapy can proceed with each individual. People with social anxiety need printed handouts that explain, with specificity, (a) how to stop automatic negative thinking, (b) how and why to use distractions, (c) how to turn automatic negative thinking neutral, (d) the importance of repetition and consistency in this process, and (e) how to gradually keep turning the tables on the automatic negative thinking until it becomes realistic and rational. We have approximately twenty (20) handouts (i.e., printed methods, strategies, concepts, and techniques) that we use to guide the person along the road to rational and realistic thinking in this step-by-step manner.
Even though automatic negative thinking and feeling are an essential part of cognitive therapy, there are many more facets to this therapy. If cognitive therapy is seen only as a thinking change process, then this therapy will not be strong enough, in most cases, to overcome social anxiety.
At this point, there are many other cognitive issues that must be presented and solved. For example, there are many cognitive methods of lessening anxiety, especially as it applies to interpersonal relations and groups. These methods must be presented, practiced, and used to give the person with social anxiety the feeling, even though it is small at first, that they have some control over their anxiety, particularly in social situations. The use of one method, such as relaxation, is never enough. Not everyone with social anxiety can learn to relax enough so that it becomes practical and useable in real-life situations at first. So, it is the therapist’s responsibility to have many ways (i.e., methods, techniques, strategies) to allow the person to begin to control their own emotions.
We have found that it is important to have the cognitive therapy written out in handout form for the patient. In this manner, they understand it better, recognize the rationale behind it, and then can practice this method or strategy (over and over again) when they are at home during the week.
At least a dozen more cognitive problems must be solved besides the two already mentioned. Lack of space prohibits a detailed analysis, but some of the every day problems that must be worked on and solved if we say we are helping people overcome social anxiety, are the person’s (a) misperception of themselves in terms of appearance, ability, and self-worth, (b) feelings of guilt and embarrassment arising from past situations, (c) anger arising from past situations, (d) self-assertion strategies to show the person they do not need to be a doormat, (e) perfectionism and how to become more realistic, and (f) procrastination habits that exist because of social anxiety worries and doubts.
In one sense, you could lump all of these things together as "irrational beliefs", but these problems do not fit neatly into this category, like automatic negative thinking. Each of these additional problems must have solutions, too, that are practical and viable in the real world. Thus, from the cognitive therapy standpoint, the therapist should have the methods and strategies in handout form so that each of the above mentioned problems may be addressed and solved. Each handout is a solution to a particular social anxiety problem. The more areas of social anxiety that are addressed, and the more solutions that are found, the quicker, easier, and stronger the healing becomes.
Again, I do not mean to imply that the social anxieties I have mentioned so far are a complete listing. There are many other issues relating to social anxiety that should be resolved. Again, we feel strongly that a written handout with the problem, the rationale, and the solution on it are essential to adequate progress in this area.
Then, it is up to patients and their motivation to carry through with the cognitive therapy. The therapy must be "practiced" at home (when they are alone and not feeling self-conscious) for approximately thirty minutes a day. Persistency is the next key. These solutions must be practiced every day for three months or longer. It is essential that the brain receive these new, rational, forward-moving messages so that thinking can be changed (i.e., the neural pathways in the mind "absorb" the cognitive therapy and it begins to become a part of the person). This constant repetition of the material that solves the social anxiety puzzle is what allows permanent change to occur in people.
pg.1 CONTINUED.........................................................................................
How is CCBT used to Overcome
Social Anxiety Disorder?
Thomas A. Richards, Ph.D., Psychologist
Director, Social Anxiety Institute
It wasn’t long ago that very few people had heard the term "cognitive - behavioral therapy".
With the outpouring of research in the 1980s, and the studies on anxiety disorders that were published in the 1990s, the term "cognitive – behavioral therapy", or CBT, gained acceptance and became well known. But even though the term itself became well known, just what "cognitive- behavioral therapy" involved was less well understood.
Meanwhile, in study after study, cognitive – behavioral therapy began to prove to be the therapy of choice for many mental health care problems, including depression and the anxiety disorders.
In fact, large-scale, long-range (i.e., longitudinal) studies over the past decade have consistently shown cognitive – behavioral therapy to be the only therapy that can be dependably relied upon to help people overcome clinical anxiety disorders.
While this was good news, some rather large questions continued to cloud the horizon. For example, each study defined CBT in a different way, and most studies were rather vague in their explanation of just what CBT was considered to be. The other big problem was that people began to think of cognitive-behavioral therapy as a "unified" therapy, or as a therapy that was "set" or always the same for every mental health care problem
In fact, CBT is a combination or a "pulling together" of any and all methods, strategies, and techniques that work to help people successfully overcome their particular emotional problems. The cognitive part of the therapy refers to thinking or learning and is the part of therapy that can be "taught" to the person. The person then needs to take what has been taught, practice it at home, and through means of repetition, get that new "learning" down into the brain over and over again.
This is essentially the same process as school or college learning. You are taught some new information or skills, and then you learn them. When you learn them well enough (through repetition), this affects your memory processes (and physiologically your brain’s neural pathways) and allows you to begin thinking, acting, and feeling differently. This takes persistence, practice, and patience, but when a person sticks with this therapy, and does not give up, noticeable progress begins to occur.
The behavioral component of CBT involves participation in an active, structured therapy group, consisting of people with clinical social anxiety. In the behavioral group, people voluntarily engage in practical activities that are mildly anxiety-causing, and proceed in a flexible, steady, scheduled manner. By moving forward in this manner, step by step, and through the use of repetition, the anxiety felt in social situations is gradually reduced. The behavioral therapy group should consist of people with social anxiety only. People with other emotional problems should not be mixed into this group. Even an "anxiety" group will not work. Because the problems are very different from each anxiety disorder to the other, the behavioral group and its activities would prove to be ineffective for people with panic, generalized anxiety, or obsessive-compulsive disorder, even though these are clinical anxiety disorders as well.
At the same time, the social anxiety behavioral group builds confidence and produces a more rational perception in the persons’ mind concerning their own abilities and competencies. The behavioral group must be structured in a step-by-step hierarchical fashion, and should include consistent cognitive reminders before and after people actively work on their specific, individualized anxiety hierarchies.
Thus, the cognitive-behavioral therapy we do for social anxiety does not contain the same information or proceed in the same manner as cognitive-behavioral therapy for other mental health care problems.
For example, CBT for depression is very different in nature than CBT for social anxiety. Because the problem is different, CBT for social anxiety contains different methods and strategies than CBT for depression, panic disorder or generalized anxiety disorder. Thus, cognitive-behavioral therapy, while always being active, structured, and solution-focused, must employ different ways of overcoming the particular emotional problem in question.
CBT is not a "set of methods" that work for all disorders. There are not simply two, three, or four strategies that work to help everyone with all kinds of mental health care problems.
Thus, the specifics or details of CBT are not universally applicable. This has been a thorny issue for professionals who do not really understand what cognitive-behavioral therapy involves. With the advent of managed care, the insurance companies now want therapists who say they can do "cognitive-behavioral" or "solution-focused" therapy. So, in order to be included in these groups and panels, professionals now will usually say they do "cognitive-behavioral therapy". But what exactly does this mean?
At this point in time, almost every licensed therapist knows the accepted terminology. The question becomes do they understand CBT and can they do it? This is only the first relevant question and the first hurdle to cross.
The second issue the professional must understand and must be able to accomplish concerns their ability to use specific CBT methods and strategies to help people with a particular disorder, such as social anxiety. When specific cognitive-behavioral therapy for social anxiety is not understood or put into place, then people with social anxiety disorder will not receive the help and assistance they need to overcome this debilitating anxiety disorder.
Because each mental health care problem is different, and because people with social anxiety disorder respond to different CBT methods, strategies, and approaches, the professional should be cognizant of how to lead, guide, and help people with social anxiety overcome this specific anxiety disorder.
I receive dozens of e-mails and other correspondence each day, with one of the recurring themes being, "I went through cognitive-behavioral therapy and I didn't get any better. What’s wrong?"
The answer to this question is another question: "Did you receive appropriate, comprehensive cognitive therapy and appropriate, comprehensive behavioral therapy, and were the cognitive and the behavioral components of the therapy "reinforced together" in your mind by your therapist?
This, of course, leads to the question: "What exactly is comprehensive cognitive – behavioral therapy, and how does it differ from traditional cognitive behavioral therapy?"
The traditional answer to "what is cognitive-behavioral therapy" has been "restructuring" the mind (i.e., thought processes) by means of disputing irrational thoughts and beliefs and substituting rational thoughts and beliefs in their place. There is usually mention of breathing exercises and relaxation techniques as well.
"Cognitive restructuring" or "learning to think rationally" are essential components of cognitive therapy for social anxiety disorder. However, while learning to notice and eradicate automatic negative thinking (and slowly moving the thinking up to automatic rational thinking) is essential for overcoming social anxiety, there are fifteen to twenty specific steps that need to be learned to be able to do this. You cannot tell a person with social anxiety to simply stop thinking negative thoughts. Obviously, the person does not want to think negatively, and if they could choose to stop thinking negatively, they would do so in a heartbeat.
We must employ very specific ways to allow the person to begin to (a) catch their own automatic negative thinking, (b) find distractions to use while therapy is in progress, and (c) begin to turn the tables on automatic negative thinking gradually. The mind will not accept "irrational positive" statements or beliefs. Repeating "I will wake up in the morning and be happy, content, and less anxious" will do absolutely nothing, because this statement is irrational, given the current state of the mind. Therefore, emphasizing positive thinking and giving out positive thinking statements to people with social anxiety disorder is going to be ineffective, and will only prove to the person that the therapist does not understand and does not know how to successfully treat social anxiety.
The mind cannot work overnight and cannot be pressured into learning things faster. So, it is important, in the cognitive process, to turn the tables on automatic negative thinking slowly. To do this, people with social anxiety learn to catch their automatic negative thoughts and then make them rationally neutral. As they find this process easier, they begin to catch more of their automatic negative thinking. This, in turn, leads to consciously turning this negative thinking into rational neutral thinking. Then, this neutral thinking is gradually moved up, always in a step-by-step manner, to a more realistic level, so that with time and repetition, the person’s thinking moves slowly upward and becomes more realistic. At first, this is a conscious process, but the more it is practiced and repeated, the more it becomes an automatic process.
Now, to get even more specific, how do we accomplish these cognitive goals? We use a series of printed handouts that accompany the office visits. The role of the therapist is to know what to do and at what pace therapy can proceed with each individual. People with social anxiety need printed handouts that explain, with specificity, (a) how to stop automatic negative thinking, (b) how and why to use distractions, (c) how to turn automatic negative thinking neutral, (d) the importance of repetition and consistency in this process, and (e) how to gradually keep turning the tables on the automatic negative thinking until it becomes realistic and rational. We have approximately twenty (20) handouts (i.e., printed methods, strategies, concepts, and techniques) that we use to guide the person along the road to rational and realistic thinking in this step-by-step manner.
Even though automatic negative thinking and feeling are an essential part of cognitive therapy, there are many more facets to this therapy. If cognitive therapy is seen only as a thinking change process, then this therapy will not be strong enough, in most cases, to overcome social anxiety.
At this point, there are many other cognitive issues that must be presented and solved. For example, there are many cognitive methods of lessening anxiety, especially as it applies to interpersonal relations and groups. These methods must be presented, practiced, and used to give the person with social anxiety the feeling, even though it is small at first, that they have some control over their anxiety, particularly in social situations. The use of one method, such as relaxation, is never enough. Not everyone with social anxiety can learn to relax enough so that it becomes practical and useable in real-life situations at first. So, it is the therapist’s responsibility to have many ways (i.e., methods, techniques, strategies) to allow the person to begin to control their own emotions.
We have found that it is important to have the cognitive therapy written out in handout form for the patient. In this manner, they understand it better, recognize the rationale behind it, and then can practice this method or strategy (over and over again) when they are at home during the week.
At least a dozen more cognitive problems must be solved besides the two already mentioned. Lack of space prohibits a detailed analysis, but some of the every day problems that must be worked on and solved if we say we are helping people overcome social anxiety, are the person’s (a) misperception of themselves in terms of appearance, ability, and self-worth, (b) feelings of guilt and embarrassment arising from past situations, (c) anger arising from past situations, (d) self-assertion strategies to show the person they do not need to be a doormat, (e) perfectionism and how to become more realistic, and (f) procrastination habits that exist because of social anxiety worries and doubts.
In one sense, you could lump all of these things together as "irrational beliefs", but these problems do not fit neatly into this category, like automatic negative thinking. Each of these additional problems must have solutions, too, that are practical and viable in the real world. Thus, from the cognitive therapy standpoint, the therapist should have the methods and strategies in handout form so that each of the above mentioned problems may be addressed and solved. Each handout is a solution to a particular social anxiety problem. The more areas of social anxiety that are addressed, and the more solutions that are found, the quicker, easier, and stronger the healing becomes.
Again, I do not mean to imply that the social anxieties I have mentioned so far are a complete listing. There are many other issues relating to social anxiety that should be resolved. Again, we feel strongly that a written handout with the problem, the rationale, and the solution on it are essential to adequate progress in this area.
Then, it is up to patients and their motivation to carry through with the cognitive therapy. The therapy must be "practiced" at home (when they are alone and not feeling self-conscious) for approximately thirty minutes a day. Persistency is the next key. These solutions must be practiced every day for three months or longer. It is essential that the brain receive these new, rational, forward-moving messages so that thinking can be changed (i.e., the neural pathways in the mind "absorb" the cognitive therapy and it begins to become a part of the person). This constant repetition of the material that solves the social anxiety puzzle is what allows permanent change to occur in people.
pg.1 CONTINUED.........................................................................................
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