Cognitive behavioral therapy

The primary aim of cognitive behavioral therapy (CBT) is to positively influence people’s emotions by changing the way they behave and think. It is scientifically recognized and the costs are covered by statutory health insurance providers. The terms behavioral therapy and cognitive behavioral therapy are generally used synonymously.

Cognitive behavioral therapy is recommended as the number one treatment of choice for anxiety and obsessive compulsive disorders. It can also be used to treat depression, eating disorders, alcohol dependence and, under certain circumstances, psychotic disorders. Psychological symptoms associated with brain injuries can also be treated with CBT.

The therapy focuses on alleviating current symptoms and developing social skills and the ability to deal with problems. The development of the mental health condition over the course of the patient’s life is only examined if no improvement can be achieved using measures relating to current problems.

An important goal of cognitive behavioral therapy is to increase patients’ independence and ability to act. It helps people to help themselves. Patients and therapists develop a working alliance. Mutual liking is usually helpful but not necessarily needed for the treatment to be successful. Patients need to be open about the thoughts, feelings and behaviors that are problematic for them. Therapists use their knowledge of the basic psychological mechanisms to bring about change in these areas.

A further goal of CBT is to change thoughts and beliefs that prove unhelpful in everyday life. This is done by observing the thoughts, emotions and behavior on which the mental health condition is based. Obstructive thoughts and behavior that are harmful to health are realistically classified and changed where possible so as to reduce emotional distress.

Health condition management is a further goal. Various factors play a role in this:

• growing knowledge of the person’s own mental illness
• management strategies – such as specific behavioral techniques for managing feelings
• acceptance of certain immutable aspects of the problems

The course of the therapy depends on individual needs and can vary greatly for different health conditions. A typical course of CBT is described here. This approach is often used to change negative thoughts and beliefs.

Behavioral analysis

At the start of the therapy, the therapist and patient describe the exact course of problematic situations. They also work together to develop an explanation for the mental health condition. Information is recorded about the situation, physical reactions, interpretations, behavior and feelings.

For example, a patient has a major issue to deal with at work and thinks “I’ve made a terrible mistake”. She experiences feelings of guilt and shame. Her behavioral response is to leave work and go straight home. She is plagued with the thought that she is worthless and quickly goes back to bed.

This example shows that the situation, thoughts, feelings and behavior all influence one other – feelings arise from the person’s cognitive evaluation of situations. It is not the mistake at work alone that led to feelings of guilt and shame, but rather the belief that it was “terrible”. From a therapy perspective, it is also important that the patient clearly lacks the skills needed to correct the mistake or talk to her boss about it in a constructive manner. Her withdrawal simply exacerbates the problem.

Self-observation

One important part of diagnosis and therapy is self-observation. This is about patients observing their own behavior during everyday life and remembering it later. It can help to record the behavior, thoughts and feelings during everyday life and use this information as a basis for dealing with the distressing feelings and unhelpful behavior during the therapy sessions.

Reviewing and changing automatic beliefs

If part of the problem is that the patient automatically evaluates him/herself and his/her environment on the basis of unhelpful beliefs, the therapy will focus on changing these. Such beliefs/assumptions are often automatic and unquestioned. One example is that someone generally regards their own performance as inadequate compared to that of others. The patient can work with the therapist to assess whether or not this is realistic and justified.

This basis is then used to develop realistic beliefs and assumptions. One example would be to accept that “It is only human to make mistakes and I can find a solution”. As patients are often unable to simply accept such alternative views, it is necessary to review beliefs regularly during everyday life. Strategies for doing this are developed during therapy. If the patient from the example above were to make another mistake at work, she could start by questioning her automatic beliefs and talking to a close colleague about her problem. Instead of going home and feeling bad, she could approach her boss and work with her to find a solution. This could ultimately even lead to feelings of pride and joy and help her continue to work without feeling distressed.

Situation analysis and confrontation are often used in CBT.

Behavior or situation analysis

A situation analysis is about taking a fresh look at emotionally distressing situations from everyday life with a therapist – as if under a magnifying glass. To do this, patients should note down several important points immediately after an experience – what exactly happened, what went through their heads at the time and how they felt. The therapy session is then used to determine the precise triggers for each of the thoughts and feelings. The thoughts related to distressing feelings are assessed to see how much they actually reflect reality. New, helpful thoughts are also developed.

Confrontation techniques

Confrontation, also known as exposure, is primarily used when treating anxiety disorders. In short, it is about addressing one’s own unreasonable anxieties to learn how to cope with them. Situations that have been avoided are actively sought. In doing so, the actual danger as well as the emotional and physical reactions are assessed objectively again and again. In the next step, it can be useful to trigger targeted feelings of anxiety to take a deeper look at how to deal with these. For this purpose, patients are asked to put themselves in situations that trigger anxiety. This is not about testing their courage or them coping with the anxiety, but about changing their physical and mental anxiety reactions. In some cases, it can also suffice to imagine the feared object or situation. Dramatizing beliefs are reviewed during this process – for example, does a racing heart rate actually mean a risk of death?

The therapy not only removes the focus from the “danger” but also practices tolerance to anxiety-induced symptoms such as breathing difficulties. Patients learn that they are not helpless in the face of anxiety but can influence and therefore control it. They gradually become able to put themselves in situations that they previously avoided out of fear of their anxiety.

Behavioral therapy is the recommended form of therapy for most anxiety disorders, several addictive disorders, obsessive compulsive disorders, during non-psychotic phases of psychotic disorders, for depression coupled with other mental health conditions and for some personality disorders such as borderline personality disorder. It is also the most recommended treatment method for psychosomatic disorders, disorders as a result of brain or nerve damage and eating disorders.

It helps if the patient is motivated to work on the problems but behavioral therapy can still achieve good results even with a lack of motivation, reduced mental capacities or a lack of trust due to previous bad experiences. The relationship between the therapist and the patient plays an important role. Depending on the type of problem involved, this can differ greatly in behavioral therapy, ranging from warm-hearted and attentive to strict and demanding.

If you experience anxiety, depression, sadness or other distressing feelings and these affect your everyday life, start by consulting your family doctor, a psychiatrist or a suitably qualified medical specialist. If the medical practitioner believes there is a need for psychotherapy, he/she can provide advice on how to proceed and establish contact with a qualified psychotherapist or psychiatrist if necessary.

Behavioral therapists in your area can be found through the Association of Statutory Health Insurance Physicians (Kassenärztliche Vereinigung), for example. Simply call 116 117 or use the online directory for physicians. If your child requires behavioral therapy, you can also search for local psychotherapists for children and adolescents.

For more information about finding a psychotherapist and understanding emotional distress, visit the website Wege zur Psychotherapie (Paths to Psychotherapy) from the Chamber of Psychotherapists (Bundespsychotherapeutenkammer).