Recommended Therapies: 1) CBTs
Cognitive Behaviour Therapy
Cognitive Behavioural Therapy (CBT) represents a family of psychological interventions (therapies) with the most extensive empirical support. CBT focuses on changing unhelpful cognitive distortions (negative thoughts, beliefs and attitudes) and behaviours to improve emotional regulation, develop better personal coping strategies, and solve our current mental health problems. The principal idea behind CBT implies that it’s not the events but our interpretation (or perception) of them that determines our emotional and behavioural responses. When we are aware of such personal interpretations (or habitual responses), we can constructively question, dispute and reframe them.
CBT is based on the concept that our thoughts (interpretations), behaviours (actions) and emotions are interconnected (affect each other) and changing one of them can break the vicious circle of our problems and improve our feelings and performance. Aaron Beck invented CBT in the 1960s. CBT is a solution-focused and action-oriented therapy and is often used to treat specific issues related to an identified problem. The therapist’s role is to assist the client in finding and practising effective strategies that address the problem and decrease its symptoms.
CBT is based on the belief that thought distortions and maladaptive behaviours play an important role in developing and maintaining disorders or problems. Therefore, we can drastically reduce the associated symptoms by learning new ways of thinking and behaving. CBT is one of the “talking therapies” and teaches us coping skills for dealing with many emotional problems. CBT is recommended as the first line of treatment for a wide range of disorders. Research suggests that CBT is most effective when combined with medication (where necessary), particularly for treating more severe mental disorders.
Cognitive Distortions
Cognitive distortions are beliefs, assumptions and thinking errors that exacerbate negative emotions and undesirable behaviours. They may include overgeneralisation, magnifying negatives, minimising positives and catastrophising. Replacing these distorted thoughts and beliefs with more realistic and practical thoughts will decrease emotional distress and self-defeating behaviours. We engage in unhelpful and distorted thinking either because of stress, sickness or poor mental habits acquired throughout our lives. If we can notice and identify our unhelpful and distorted thinking patterns, we can question them, dispute them and replace them with more realistic and helpful alternatives. The following is a list of common unhelpful ways of thinking, which could help us spot such distortions and question their validity.
Filtering: Filtering (mental or cognitive filtering) means focusing on only what our mental filter allows (often only the negative details) and ignoring the rest (all positive aspects of a situation). Cognitive filtering is like looking through a pair of dark and gloomy glasses.
Black and White Thinking: We see things as all or nothing (good or bad - right or wrong) in black and white thinking (or polarised thinking). We become a perfectionist. If what we want is not perfect or complete, it’s unacceptable. There is no middle ground (nothing in between). We lose our nuanced judgement (with no shades of grey - forbidding complexity). A person with black-and-white thinking sees things only in extremes.
Generalising: Generalising (over-generalising) happens when we wrongly come to a general conclusion based on limited evidence. For example, if we’ve done something wrong once or twice, we accuse ourselves of being clumsy, worthless or incompetent, and we expect such failures to happen repeatedly. A person with this way of thinking may see a couple of unpleasant events as part of a never-ending pattern of defeat.
Jumping to Conclusions: A person who jumps to conclusions assumes they know what others feel and think or exactly why they acted the way they did. Such a person believes they know how others think, as though they could read their mind (mind-reading). Jumping to conclusions can also manifest as fortune-telling (predicting), where a person believes they know what will happen. For example, someone may anticipate that things will turn out badly in their next relationship and feel convinced that their prediction is already a fact, so why bother dating?
Catastrophising: When people catastrophise, they imagine and believe the worst possible thing will happen. They expect disaster. This type of thinking is also known as magnifying negatives. It can also appear in its opposite form, minimising positives, which has been identified as a pessimistic explanatory style.
Personalising: Personalising involves interpreting external events as though they are directly related to us or what we have done rather than attributing them to other factors. For example, we may believe that everything others do or say is in some way related to us. In this way of thinking, we take everything personally, even when it is not meant that way. Personalising leads to blaming ourselves or others for everything wrong or seeing others as unkind and mean.
The fallacy of Control: It is possible (especially in depressive situations) that people may feel helpless and think that they have little or no control over the events in their lives. Alternatively, feeling that everything relies on them. These extreme perceptions of control, either too much or too little, promote guilt, depression and hopelessness. People who think they have too little or no control over the events in their lives may stop doing things that could improve their situation. They may even end the activities they used to enjoy. People who feel they should have total control and everything depends on them may become angry or anxious when they realise things aren’t happening their way. They may also take responsibility for things outside their control, adding to their distress and guilt.
Being Judgemental: We often evaluate and judge ourselves, others, and events around us based on limited knowledge and understanding, which, of course, is not always correct or helpful. We may feel resentful because we think that we know what’s right (appropriate), as we apply our own standards against every situation, trying to determine its fairness, but of course, we end up feeling offended, angry and even hopeless because things will not always work out our way. Moreover, being judgemental essentially means thinking, speaking or behaving in a critical and condemning manner. When we are judgemental, we are nit-picking and constantly find faults with others, their ideas or behaviours. In short, we judge, blame and condemn everyone and everything as wrong, stupid or unworthy. Being judgmental also extends to ourselves, leading to many problems such as anxiety, low self-worth and depression.
Blaming: When people blame, they hold others responsible for their emotional pain. They are also susceptible to blaming themselves for every problem, even those clearly outside their control. “I only did it because you don’t love me.” - “If you hadn’t done x and y, I wouldn’t have to do z.” - “This is all your fault.” - “You never listen to me! You only care about your friends.” Things that happen to us are often the result of multiple contributing factors and can be caused by a combination of our actions and those of others. As well as weakening our relationships, blaming others and refusing to take responsibility for our shortcomings and mistakes can damage our mental health, ability to solve problems, and potential to flourish.
“Should”, “Must” and “Ought to” Statements: Thinking or saying, “You or I should, or shouldn’t”, “You or I must, or mustn’t”, or “You or I ought to, or ought not to” puts unnecessary pressure on us and sets up unrealistic expectations. Should, must and out to statements appear as standards that we should live our lives (rules of life). People who break these rules (including ourselves) make us angry, upset and violated. People who frequently use these terms may believe they are trying to motivate themselves as if they must be punished, pressured or ordered to do the right thing. The emotional consequences are guilt, anger, frustration and resentment.
Emotional Reasoning: The distortion of emotional reasoning can be summed up by the statement, “If I feel that way, it must be true that . . .”. Sometimes, people automatically believe what they feel, regardless of valid evidence. Emotional reasoning amplifies the effects of other cognitive distortions, such as magnifying, generalising or personalising. Sometimes, our emotions can overrule our rational thinking and reasoning. Emotional reasoning happens when a person’s emotions control their thinking and behaviour, blocking rationality and the available evidence. The person who engages in emotional thinking assumes that their emotions reflect how things are and bases their judgement on their feelings triggered for unknown reasons.
Labelling: Labelling (or mislabelling) happens when a person generalises a quality of themselves or others into a negative global judgment by giving it a label. This cognitive distortion is an extreme form of over-generalisation. Instead of describing an error in the context of a specific situation, the person attaches an unhealthy universal label to themselves or others. For example, they may say, “I’m a loser” or “he is stupid” in a situation where someone failed at a specific task. Labelling involves descriptions that are often emotional and highly loaded. Additionally, such labels are always hurtful and wrong.
Correcting Wrong Beliefs and Assumptions
The first step in correcting our unhelpful thinking is learning to observe our thoughts and become aware of our cognitive distortions. At this stage, it can be beneficial to seek the support of a coach or a therapist. We need to be aware of our underlying beliefs and assumptions (core beliefs) and that they are just our subjective views, not the objective truth, and we can change them.
We should learn about common cognitive distortions (listed above) that are part of human thinking. It’s easy to adopt them, but it’s often difficult to see them for what they are and resist them. Again, a coach or therapist's support would greatly help us identify and change them. The following suggestions have proved useful.
Ask clarifying and probing questions.
Get the necessary knowledge about your condition.
Research the subject matter.
Analyse the evidence.
Decide on reflection, not impulse.
What’s important now?
What’s my responsibility in this situation?
What’s possible?
What are the alternatives?
What are my choices?
Who can I turn to, rely on, talk and consult with?
What’s the best course of action?
What’s the first thing I need to do? (And DO it with no hesitation.)
Self-Management and CBT
Self-management is defined as the individuals’ response-ability to manage their physical and emotional symptoms, which in turn leads to changes in lifestyle changes inherent in dealing with and overcoming mental health conditions. Followings are essential steps that support self-management.
self-monitoring,
goal setting (dream goals and SMART goals),
action planning,
disputing the automatic (habitual) negative thoughts,
regulating the emerging emotions,
managing the environment,
building and using social support,
learning about our condition and its potential treatments,
seeking help (the sooner, the better).
Third Wave CBT
The “first wave” of behavioural therapies was characterised by behaviourism, a school of psychology that introduced classical and operant conditioning and was dominant around the mid-20th century. Behaviourism still significantly influences psychology and the study of behaviours in people and animals. Classical conditioning involves associating an involuntary response with a stimulus, while operant conditioning associates a voluntary behaviour with a consequence. The learner is rewarded with incentives in operant conditioning, while classical conditioning involves no such enticements.
Classical conditioning (a form of associative learning) was first studied by Ivan Pavlov, a Russian physiologist (1849-1936) who experimented with dogs to explore digestion (1897). Pavlov noticed dogs salivating in response to a bell and realised that this was a learned response involving pairing a stimulus (the sound of a bell) with an unconditioned stimulus (the presence of food).
Operant conditioning (a form of instrumental learning) uses either reinforcement or punishment to increase or decrease the incidence of behaviour, where an association is formed between the behaviour and its consequences. B. F. Skinner (American psychologist, 1904-1990) developed operant conditioning to strengthen behaviour, and his writings mainly explain the application of operant conditioning to human behaviour.
Albert Ellis and Aaron Beck pioneered the “second wave” of behavioural therapies with cognitive behavioural therapy (CBT), which integrated a person’s thoughts and beliefs with their behaviours and emotional experiences, such as depression.
The “third wave” of cognitive behavioural therapies consists of a group of emerging psychotherapy approaches (mostly since 2004) that represent an evolution of traditional CBT (founded by Ellis and Beck). The third wave of therapies prioritises the holistic promotion of psychological and behavioural processes associated with health and well-being over the reduction or elimination of psychological and emotional symptoms (although those are often the side effects of such therapies). In other words, the third wave of CBT is interested in helping people become more at ease with who they are and the world they experience. The focus is less on removing what is deemed wrong (shortcomings or flaws) and more on adding to our strengths (abilities or virtues) and adjusting the way we see the world and ourselves within it.
In these latest behavioural therapies (the third wave), concepts such as metacognition, acceptance, mindfulness, personal values and spirituality are often incorporated into the traditional CBT. Moreover, rather than focusing on the content of a person’s thoughts and internal experiences, the third wave focuses on the context, processes and functions of how people relate to their inner experiences (thoughts, urges and sensations). In other words, the third wave of CBT is a movement away from what we think and feel, focusing on how we relate to what we think and feel.
The third wave of cognitive behavioural therapies utilises many strategies and interventions that complement traditional CBT interventions such as exposure therapy (systematic desensitisation) and behavioural activation. However, the new approach led to many focused interventions, including Acceptance and Commitment Therapy (ACT), Dialectical Behaviour Therapy (DBT), Mindfulness‐Based Cognitive Therapy (MBCT), Functional Analytic Psychotherapy (FAPT), Meta‐Cognitive Therapy (MCT) and a few others.
In short, the differences in the third wave CBT can be summarised as a) more focus on health rather than dysfunction; b) a more holistic approach towards the person; c) being more concerned about the context, not just the flaws; d) aiming to increase skills and abilities, instead of just trying to eliminate symptoms; e) process-based rather than focusing just on solutions.
Mindfulness-Based Cognitive Therapy
The theories behind mindfulness-based approaches work on the idea that being aware of the present and not focusing on the past or the future allows an individual to deal much better with current stressors and distressing feelings because mindfulness makes us more flexible and receptive. Mindfulness also helps us develop three valuable skills: a) intentionally paying attention to moment-by-moment events as they unfold in our lives (both internally and externally), b) noticing our habitual reactions characterised by aversion or attachment, and c) cultivating the ability to respond with an attitude of open-mindedness, compassion and curiosity.
To a degree, mindfulness-based cognitive therapy (MBCT) is based on the mindfulness-based stress reduction programme (MBSR) developed by Jon Kabat-Zinn (1970s). MBCT was created by Zindel Segal (Ukrainian cognitive psychologist), Mark Williams (clinical psychologist, University of Oxford) and John Teasdale (Oxford and Cambridge Universities, UK), who used the theory of ICS (Interacting Cognitive Subsystems) to explain MBCT.
Interacting Cognitive Subsystems (ICS) is based on the thinking of John Teasdale and Philip Barnard (neuroscience, Cambridge University, UK). They suggested that our minds have two main modes for receiving and processing information (both cognitively and emotionally). The two modes of mind are the “doing” mode (driven mode) and the “being” mode. The doing mode is goal-oriented and is triggered by discrepancies between how things are and how the mind wishes them to be. The second mode, the being mode, is not focused on achieving specific goals but emphasises “accepting and allowing” without any immediate pressure to change anything.
In Barnard and Teasdale’s ICS model (1991), mental health is related to an individual’s ability to quickly move among the two modes of mind (being and doing modes). Individuals who can flexibly move between the modes of mind based on environmental conditions are in the most favourable state. The ICS model theorises that the “being” mode is the most likely mode of mind that will lead to lasting emotional changes (and emotional stability). Therefore, to prevent relapse in depression, cognitive therapy must promote this mode. This idea prompted Teasdale to develop MBCT, which supports the “being” mode.
Another component of ICS is metacognitive awareness, the ability to experience negative thoughts and feelings as mental events that pass through the mind rather than as a part of the self. Individuals with high metacognitive awareness can more easily avoid depression and negative thoughts than individuals with low metacognitive awareness. Metacognitive awareness is regularly presented as an individual’s ability to decentre. Decentring is the ability to perceive thoughts and feelings as both impermanent and objective occurrences in the mind.
The MBCT is an eight-week group intervention programme, where participants receive a two-hour course each week, plus a one-day long class after the fifth week. However, much of the work is done outside the classes, where participants use guided meditations and cultivate mindfulness daily. They learn to concentrate with purpose but without judgement in each moment. Mindfulness helps participants become aware of their feelings (instead of focusing on changing them) and recognise that holding onto some of their feelings could be ineffective, if not destructive.
MBCT was initially developed specifically to target vulnerability to depressive relapse and as an alternative to antidepressant maintenance of depressive symptoms. Throughout the program, patients learn mind management skills that help them heighten their metacognitive awareness, accept negative thought patterns, and respond skilfully. They learn to decentre their negative thoughts and feelings, moving their mind from an automatic thought pattern to conscious emotional processing.
The UK National Institute of Clinical Excellence (NICE) has endorsed MBCT as an effective treatment for the prevention of relapse in depression. Research has shown that people who have been clinically depressed three or more times have found the program significantly helpful. Moreover, the evidence from two randomised clinical trials of MBCT indicated that it reduces relapse rates by about 50% among patients who suffer from recurrent depression. MBCT has also been used to treat physical symptoms and anxieties associated with other diseases, such as diabetes or cancer.
Resources and Further Reading
Claessens, M. (2010). Mindfulness-based third-wave CBT therapies and existential phenomenology. Friends or foes? Existential Analysis: Journal of the Society for Existential Analysis, 21(2).
Brown, L. A., Gaudiano, B. A., & Miller, I. W. (2011). Investigating the similarities and differences between practitioners of second-and third-wave cognitive-behavioural therapies. Behaviour modification, 35(2), 187-200.
Hunot, V., Moore, T. H., Caldwell, D. M., Furukawa, T. A., Davies, P., Jones, H., ... & Churchill, R. (2013). ‘Third wave cognitive and behavioural therapies versus other psychological therapies for depression. Cochrane Database of Systematic Reviews, (10).
Hayes, S. C., & Hofmann, S. G. (2017). The third wave of cognitive behavioural therapy and the rise of process‐based care. World Psychiatry, 16(3), 245.
Teasdale, J. D., Segal, Z., & Williams, J. M. G. (1995). How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help? Behaviour Research and Therapy, 33(1), 25-39.
Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V. A., Soulsby, J. M., & Lau, M. A. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of consulting and clinical psychology, 68(4), 615.
Segal, Z. V., Teasdale, J. D., & Williams, J. M. G. (2004). Mindfulness-Based Cognitive Therapy: Theoretical Rationale and Empirical Status.
Segal, Z. V., & Teasdale, J. (2018). Mindfulness-based cognitive therapy for depression. Guilford Publications.
