Understanding Cognitive Behavioral Therapy: Techniques, Applications, and Limitations

Developing psychological illnesses and suffering because of it has become a widely accepted reality in the world today. As a consequence of technological advancement, dilution of taboos related to psychological disorders, and understanding of human behaviour in the broader context, individuals are becoming aware day by day about the different disorders and are stepping forward to take up treatments and medications, without feeling any sense of shame, guilt, inferiority or fear. Cognitive Behavioural Therapy is one of the most effective therapeutic interventions which is extensively used by therapists all around, to understand and treat psychological disorders and issues.

What is CBT? 

Cognitive behavioural therapy is a therapeutic intervention, which is also known as ‘talking therapy’, aims to address irrational and maladaptive thoughts, beliefs, rationales, feelings, expectations and judgements to bring about a positive change in the behaviour. According to this intervention, the cognitions, emotions and behaviours of an individual interact together, in a comprehensive fashion that leads an individual to adjust to their surrounding environment effectively.

If there is some problem in the emotions or thoughts of the person, it will be reflected in their behaviour. The greater the distance between their maladaptive perception and reality, the greater the intensity of their dysfunctional behaviour. In other words, negative and unrealistic thoughts, when distressing, result in problems. When a person suffers from psychological distress, how they interpret situations becomes skewed or biased, and often lacks reality orientation, which in turn harms the actions they take.

CBT is evidence-based, cost-effective, and has a wide scope of testing, measurement, and in-depth analysis concerning addressing the root of the problem. It is found useful in treating several problems like anxiety disorders (like GAD and Phobia), personality disorders, substance abuse disorders, acquired brain injury, somatic disorders, eating disorders (like Bulimia Nervosa), sexual dysfunction, anger management, addiction, and the like. 

To understand more about the process of Cognitive Behavioral Therapy, here is an example of a case, as cited by the American Psychological Association: Case Study: Cognitive Behavioral Therapy

Here, the client is seen suffering from PTSD (Post-Traumatic Stress Disorder: where the person tends to exhibit maladaptive behavioural, emotional and cognitive reactions which are found to be a reflection of some traumatic experience) as a consequence of her traumatic experience of the Warfield. After conducting objective assessments, it was decided that the irrational beliefs and co-morbid symptoms of the client would be addressed through the use of CBT, specifically, trauma-focused cognitive therapy and her grasp of reality was addressed. With CBT being an umbrella term, here are different cognitive behavioural therapeutic techniques that help people to understand and deal with the distress-causing factors and address the main cause underlying it.

1. Cognitive Therapy

Cognitive Therapy or CT is based on the cognitive approach by Aaron T. Beck, comprising of three elements, namely, the Cognitive Triad of negative automatic thinking, negative self-schemas (like “I’m useless, and I can’t do anything to make my life better”), and faulty information processing (like “people are being nice by appreciating me so that I don’t feel bad about my worthlessness”).

The negative beliefs that produced them can be challenged and changed. Beck believed that the persistence of these negative thoughts can eventually lead to depression, which again, will produce negative thoughts and therefore trap the person in this terrible loophole.

The CT thus addresses and explores these negative perceptions about the self, world and future, counters them by distancing them from reality and helps the person to change, isolate or replace them with positive attitudes and practices. It can be used to deal with Generalized Anxiety Disorder, Inferiority Complex, Depression and other types of mood disorders. 

2. Rational Emotive Behavioural Therapy

Also known as REBT, this therapy was first used by Albert Ellis to resolve emotional and behavioural issues in individuals, by targeting their irrational beliefs to change them into more rational ones. Albert Ellis (1957, 1962) proposes that each of us holds a unique set of assumptions about ourselves and our world that serve to guide us through life and determine our reactions to the various situations we encounter.

Unfortunately, due to several factors like past experiences, personality disposition or relationships affecting one’s self-esteem, more and more irrational beliefs are generated in them, which Ellis referred to as the ‘irrational assumptions’. REBT may use tactics like sensitivity therapy or humour to address such thoughts, by taking the irrational belief separately from the person him/herself.

Here is an example of REBT: where the professional counsellor uses a systematic and logical procedure to point out that the client is above their irrational thoughts and expectations and alter their thinking to adapt to the demands of their surroundings effectively, without feeling guilty of “not doing enough”. One of the important theories explaining CBT, but essentially implied in REBT, is the ABC technique of Irrational beliefs, as proposed by Albert Ellis (1957) :

A – Activating the event or object situation which is responsible for eliciting an emotional response.

B – Beliefs, i.e., the negative thoughts that occur to them. 

C – Consequence of heightened emotional dysregulation and negative thoughts. 

People suffering acute stage fright, moderate neuroticism, Generalized Anxiety Disorder, panic attacks or social anxiety, can benefit from this therapy.

3. Cognitive Restructuring or Reframing

It is a type of cognitive behavioural therapy that attempts to shift the focus of the individual from the negative thoughts or beliefs to the more positive or brighter side, to restructure or reframe them, by exploring, challenging or rectifying the different beliefs and images of the person that are presumably maladaptive, and causing the person to face difficulty in coping with different situations in personal, social or occupational facets of life. It is beneficial to treat personality disorders like Narcissistic Personality Disorder or Histrionic Disorder, and anxiety disorders like Generalized Anxiety Disorders, Depression, and Eating Disorders.

4. Exposure Therapy

Often, people hold several false or irrational beliefs causing intense fears or expectations from certain situations, objects, places or persons in many cases, which make them react unreasonably, being dysfunctional, for example, by avoiding it. In such cases, the person is exposed to their object of fear slowly and steadily, in due progression of the sessions, so that the person learns to overcome their fear.

The goal of exposure therapy is to help you overcome your fear so the object, activity, or situation doesn’t cause anxiety, and you can engage with it meaningfully. “A motto of exposure therapy is ‘Let’s get comfortable with being uncomfortable,” says Courtney DeAngelis, a licensed clinical psychologist at Columbia University Medical Center.

It is very useful to treat different types of phobias, essentially specific phobias (like phobia of a certain animal, water, height, etc), Obsessive Compulsive Disorder, acute Post Traumatic Stress Disorder, and the like. However, it is important to know the medical history of the client so that subjecting him/her to exposure therapy doesn’t

5. Systematic Desensitization

Systematic Desensitization is a type of Exposure therapy that is used under the wide array of Cognitive Behavioural Therapy. It follows the principle of Classical Conditioning, where the person is gradually exposed to their object of fear, bit by bit, and this method is called ‘graded exposure’ (i.e, the person is exposed to the least anxiety-producing stimulus first, and then steps progressively, in the hierarchy, to the most anxiety-producing stimulus).

For example, if the person has a phobia against spiders, then the process of systematic desensitization will start with talking about spiders, then looking at its picture, looking at a real one from afar, then looking at it from a close distance, and then touching it.

This therapeutic strategy assumes that people are conditioned to associate an unconditioned response with a neutral stimulus, thus eliciting a conditioned response to the conditioned stimuli. This very assumption is the basis of the development of a phobia. Under such conditions, systematic desensitization is used to counter condition the person’s behaviour so that they are desensitized towards their phobic stimulus, and it does not elicit any anxiety in them anymore. 

6. Dialectical Behaviour Therapy

Also known as DBT, it is a modified version of CBT that helps people deal with the influx of emotions, exhibition of self-destructive behaviour, develop better coping strategies, and handle emotional reactions effectively so that the person can live in the present by concentrating on what’s present and not on what has happened. The approach of DBT believes that life itself is complex so people need to have a simple and flexible approach to live in it.

It is a proven structured intervention of psychotherapy that helps people to counter suicidal thoughts, negotiate with social anxiety, and treat emotional dysregulation. It was essentially used to treat Borderline Personality Disorder as a form of psychotherapy, however, it was later established to be useful for treating other disorders such as eating disorders, severe depression, or psychotic disorders.

Many psychotherapists however classify Dialectical Behaviour Therapy as a type of psychotherapy. It is unique to DBT, in that it acknowledges life to be meaningful, and promotes change like acceptance towards the different stressors of life, in a way that a state of balance is generated between the positive and negative forces of life.

It should be noted that the different types of cognitive behavioural therapies do overlap to a great extent, but they hold their uniqueness in terms of their overall focus on the psychological issue. It is the perception, expertise, knowledge base and grip of the therapist on the different symptoms and their true aetiology, which is responsible for choosing the best possible strategy for the individual suffering from psychological distress – from which they will benefit the most.

Limitations of Cognitive Behavioral Therapy

1. Not every individual can respond well to CBT. So sticking to it may cause potential risk to the psychological wellbeing of the client. 
2. Difficulty with the diagnosis is a serious limitation because if the therapeutic intervention starts with a false diagnosis, it is bound to end up being harmful to the client.
3. The theories that we rely on for conducting CBT, are itself narrow in scope. They solely focus on our higher level mental functioning, whereas our thought processes are just a part of being a human. 
4. To implement CBT, it is of utmost importance for the therapist to be qualified and experienced enough to start and persist throughout the process to ensure a successful outcome. But often it is seen, that either the therapists are not qualified or experienced enough to conduct CBT sessions, or they are unable to implement the strategies tactfully, thus aggravating the existing problem.
5.  CBT is more like a directive therapy where the therapist decides what is right or wrong for the client, sometimes being forceful, hardly allowing the person his/her liberty to choose their course of action as they are believed to have lost their reality orientation to such an extent that presently they are unable to cope up with the demands of their surrounding environment.