THERAPY AT A GLANCE
(CBT, DBT, & Family Therapy)
COGNITIVE-BEHAVIORAL THERAPY is a form of psychotherapy that emphasizes the important role of thinking in how we feel and what we do.
Cognitive-Behavioral Therapy (CBT) is a general term for different types of therapy such as Rational Emotive Behavior Therapy and Dialectic Behavior Therapy. Most cognitive-behavioral therapies have similar characteristics.
- CBT is based on the idea that our thoughts cause our feelings and behaviors rather than external things, like people, situations, and events. The benefit of this idea is that we can change the way we think in order to feel or act better even if the situation does not change.
- CBT can be brief and time-limited. CBT is considered among the most rapid in terms of results obtained. The average number of sessions clients receive (across all types of problems and approaches to CBT) is only 16. Other forms of therapy, like psychoanalysis, can take years. What allows CBT to be briefer is its highly instructive nature and the fact that it makes use of homework assignments.
- CBT is time-limited in that we help clients understand at the very beginning of the therapy process that there will be a point when the formal therapy will end. The ending of the formal therapy is a decision made by the therapist and client. Therefore, CBT is not an open-ended, never-ending process.
- A sound therapeutic relationship is necessary for effective therapy, but not the focus. Some forms of therapy assume that the main reason people get better in therapy is because of the positive relationship between the therapist and client. CBT therapists believe it is important to have a good, trusting relationship, but that is not enough. CBT therapists believe that the clients change because they learn how to think differently and they act on that learning. Therefore, CBT therapists focus on teaching rational self-counseling skills.
- CBT is a collaborative effort between the therapist and the client. CBT therapists seek to learn what their clients want out of life (their goals) and then help their clients achieve those goals. The therapist’s role is to listen, teach, and encourage, while the client’s role is to express concerns, learn, and implement that learning.
- CBT teaches the benefits of feeling, at worst, calm when confronted with undesirable situations. It also emphasizes the fact that we have our undesirable situations whether we are upset about them or not. If we are upset about our problems, we have two problems — the problem, and our upset about it. Most people want to have the fewest number of problems possible. So when we learn how to more calmly accept a personal problem, not only do we feel better, but we usually put ourselves in a better position to make use of our intelligence, knowledge, energy, and resources to resolve the problem.
- CBT uses the Socratic Method. CBT therapists want to gain a very good understanding of their clients’ concerns. That’s why they often ask questions. They also encourage their clients to ask questions of themselves, like, “How do I really know that those people are laughing at me?” “Could they be laughing about something else?”
- CBT is structured and directive. CBT therapists have a specific agenda for each session. Specific techniques and concepts are taught during each session. CBT focuses on the client’s goals. We do not tell our clients what their goals “should” be, or what they “should” tolerate. We are directive in the sense that we show our clients how to think and behave in ways to obtain what they want. Therefore, CBT therapists do not tell their clients what to do — rather, they teach their clients how to do.
- CBT is based on an educational model. CBT is based on the scientifically supported assumption that most emotional and behavioral reactions are learned. Therefore, the goal of therapy is to help clients unlearn their unwanted reactions and to learn a new way of reacting. Therefore, CBT is more than just talking. The educational emphasis of CBT has an additional benefit — it leads to long term results. When people understand how and why they are doing well, they know what to do to continue doing well.
- CBT theory and techniques rely on rational thinking that it is based on fact. Often, we upset ourselves about things when, in fact, the situation isn’t like we think it is. If we knew that, we would not waste our time upsetting ourselves. Therefore, CBT encourages us to look at our thoughts as being hypotheses or guesses that can be questioned and tested. If we find that our hypotheses are incorrect (because we have new information), then we can change our thinking to be in line with how the situation really is.
- Homework is a central feature of CBT. If when you attempted to learn your multiplication tables you spent only one hour per week studying them, you might still be wondering what 5 X 5 equals. You very likely spent a great deal of time at home studying your multiplication tables, maybe with flashcards. The same is the case with psychotherapy. Goal achievement could take a very long time if a person were to only think about the techniques and topics taught for one hour per week. That’s why CBT therapists assign reading assignments and encourage their clients to practice the techniques learned.
- Cognitive Behavioral Therapy has been found to be effective with mood, anxiety, personality, eating, substance use, and psychotic disorders. There are different goals for different disorders. CBT has been found to be more effective than medication alone for mild to moderate depression and anxiety. CBT in conjunction with medication (not medication alone) is the best course of treatment for severe depression and anxiety. CBT with personality disorders is often more behaviorally focused at first, meaning, focusing on changing behavior and then looking at deeply ingrained beliefs. CBT with psychosis helps people develop social skills, problem solving skills, decision making skills, and countering delusional thoughts. CBT and SSRIs is the best combination for anorexia.
DIALECTICAL BEHAVIOR THERAPY was originally developed for people with Borderline Personality Disorder. Clients with BPD who received CBT found the focus on change that is inherent to CBT invalidating of their emotions.
- DBT was developed as an acceptance-based intervention. Validation strategies were developed to communicate to the client their feelings were acceptable and understandable, including those that were self-harming, and made real sense in some way. Further, therapists learned to highlight for clients when their thoughts, feelings, and behaviors were “perfectly normal,” helping clients discover that they had sound judgment and that they were capable of learning how and when to trust themselves. The new emphasis on acceptance did not occur to the exclusion of the emphasis on change: Clients also must change if they want to build a life worth living. Thus, the focus on acceptance did not occur to the exclusion of change based strategies; rather, the two enhanced the use of one another.
- In order to balance the strategy of acceptance versus change, dialectical strategies served to prevent both therapist and client from becoming stuck in the rigid thoughts, feelings, and behaviors that can occur when emotions run high, as they often do in the treatment of clients diagnosed with BPD. Dialectical strategies look at all parts of a situation in a holistic, rather than black and white, manner.
- DBT includes group skills training, individual therapy, telephone check-ins, and a consultation group for the therapist. This was how it was developed and conducted in a research setting. Many people find it useful to have DBT skills training in individual therapy or to attend a group but not have individual therapy. It is best to evaluate individual needs to determine what format is the best fit.
- DBT is not just for people with Borderline Personality Disorder anymore! It has been found helpful for people with anxiety and depression as well as Antisocial Personality Disorder.
- The general goals of skills training are to learn and refine skills in changing behavioral, emotional, and thinking patterns associated with problems in living that are causing misery and distress.
- The Specific Goals of skills training are:
- Core mindfulness training: Learning to go within to find oneself and learning to observe oneself.
- Interpersonal effectiveness: Learning to deal with conflict situations, to get what one wants and needs, and to say no to unwanted requests and demands. It focuses specifically on doing this in a manner that maintains self-respect and other’s liking and/or respect.
- Emotional regulation training: Enhancing control of emotions.
- Distress tolerance training: Discusses the connection between the inability to tolerate distress and impulsive behavior which reduces intolerable distress such as alcohol, drugs, eating, spending, and self harm.
FAMILY THERAPY is a form of psychotherapy that involves all the members of a nuclear or extended family. It may be conducted by a pair or team of therapists. Although some forms of family therapy are based on behavioral or psychodynamic principles, the most widespread form is based on family systems theory. This approach regards the family, as a whole, as the unit of treatment, and emphasizes such factors as relationships and communication patterns rather than traits or symptoms in individual members.
Family therapy is often recommended in the following situations:
- Treatment of a family member with schizophrenia or bipolar disorder. Family therapy helps other family members understand their relative’s disorder and adjust to the psychological changes that may be occurring in the relative.
- Families with problems across generational boundaries. These would include problems caused by children being reared by grandparents.
- Families that may not have internal problems but may be troubled by outsiders’ judgmental attitudes such as gay couples rearing children.
- Families with members from a mixture of racial, cultural, or religious backgrounds.
- Families who are undermining the treatment of a member in individual therapy.
- Families where the identified patient’s problems seem inextricably tied to problems with other family members.
- Blended families with adjustment difficulties.
Family therapy tends to be short-term treatment, usually several months in length, with a focus on resolving specific problems. It is not normally used for long-term or intensive restructuring of severely dysfunctional families.
In family therapy sessions, all members of the family and the therapist are present at most sessions. The therapists seek to analyze the process of family interaction and communication as a whole; they do not take sides with specific members. They may make occasional comments or remarks intended to help family members become more conscious of patterns or structures that had been previously taken for granted. Family therapists, who work as a team, also model new behaviors for the family through their interactions with each other during sessions.
Family therapy is based on family systems theory, which understands the family to be a living organism that is more than the sum of its individual members. Family therapy uses “systems” theory to evaluate family members in terms of their position or role within the system as a whole. Problems are treated by changing the way the system works rather than trying to “fix” a specific member. Family systems theory is based on several major concepts:
The identified patient (IP) is the family member with the symptom that has brought the family into treatment. The concept of the IP is used by family therapists to keep the family from scapegoating the IP or using him or her as a way of avoiding problems in the rest of the system.
Homeostasis (balance) means that the family system seeks to maintain its customary organization and functioning over time. It tends to resist change. The family therapist can use the concept of homeostasis to explain why a certain family symptom has surfaced at a given time, why a specific member has become the IP, and what is likely to happen when the family begins to change.
The extended family field refers to the nuclear family, plus the network of grandparents and other members of the extended family. This concept is used to explain the intergenerational transmission of attitudes, problems, behaviors, and other issues.
Differentiation refers to the ability of each family member to maintain his or her own sense of self, while remaining emotionally connected to the family. One mark of a healthy family is its capacity to allow members to differentiate, while family members still feel that they are “members in good standing” of the family.
Triangular relationships occur whenever any two persons in the family system have problems with each other. They will “triangle in” a third member as a way of stabilizing their own relationship. The triangles in a family system usually interlock in a way that maintains family homeostasis. Common family triangles include a child and its parents; two children and one parent; a parent, a child, and a grandparent; three siblings; or, husband, wife, and an in-law.
Family therapists will usually evaluate a family for treatment by scheduling a series of interviews with the members of the immediate family, including young children, and significant or symptomatic members of the extended family. This process allows the therapist to find out how each member of the family sees the problem, as well as to form first impressions of the family’s functioning. Family therapists typically look for the level and types of emotions expressed, patterns of dominance and submission, the roles played by family members, communication styles, and the locations of emotional triangles. They will also note whether these patterns are rigid or relatively flexible.
Preparation also usually includes drawing a genogram, which is a diagram that depicts significant persons and events in the family’s history. Genograms also include annotations about the medical history and major personality traits of each member. Genograms help in uncovering intergenerational patterns of behavior, marriage choices, family alliances and conflicts, the existence of family secrets, and other information that sheds light on the family’s present situation.