Cognitive Behavioral Therapy

Thunderwolf, MSN, RN

I remember, in my Grad school training as a counselor long ago, a saying my professor drilled in our heads. The saying was... "Stop, Think." Simple, but to the point...and yet, very powerful. The reason why it is of such value is that most people do not do this when times get tough or stressful. During stress, we often "react and respond"... without much thought behind it. This "reacting without thought" often jacks up our own stress response to higher levels during the stressful event or leaves us with the "after the crisis" guilt, which just contributes to additional stress.

The premise behind Cognitive Behavioralism or CB is that our response or actions to a stressful event is a result of faulty reasoning or little reasoning at all. As a result of poor reasoning, we simply react or behave ineffectually....severely limiting our choices. If we had evaluated things beforehand in a more systematic way and applied this new reasoning during the stressful event, our choices would have been much clearer to us... and our response to stress much less.

Faulty reasoning was first brought to our attention by one of the Godfather's of therapy, Albert Ellis, back in the 1950s. Albert Ellis developed the approach of Rational-Emotive Therapy or RET....which many clinicians still use in some shape or form. Ellis' approach was earth-shattering during his day, a true pioneer because he was very confronting in shaking people awake out of the lull of their mental untruths. In Ellis' approach, one of these faulty reasonings or untruths were called "musturbations"... such as "I must do this or think that" or "he/she must do this or think that". The challenge was to confront the evidence for why such things "must" be a certain way. A very valuable approach in that this type of thinking is very black and white and is very ineffective in a world which is gray. Ellis also confronted other types of faulty reasoning as well....such as "unconditional shoulds"... such as "I should do this or think that and so should he or she". The "shoulds", as they were called, were a cognitive roadblock in improving one's situation. The "shoulds" were also challenged.

When I was a counselor in my day, I was often able to pick out the faulty reasonings in my clients pretty easily...the faulty logic or mental roadblocks. The key as a clinician was to assist my clients in self-discovering them for themselves and NOT by my telling them...much less confronting than Ellis. The techniques that allowed this to happen was by my use of client journaling, role-playing, art therapy, bibliotherapy, and recordings (in session and out of session). Let me provide one example. I had one client, a college student, who came in for counseling because she often found that she procrastinated in school and in life. She called this her "start and stop, and never getting anything done." In the first 10 minutes of coming together, it became very apparent to me as to why and introduced her to the use of self-tape recording with the use of journaling. Session 2, she hadn't got it yet. Session 3, she did. "I'm a 'But' Person", she exclaimed loudly at the beginning of our session, almost in tears..."I understand why now... I just never paid much attention to what I was telling myself. I am holding myself back." She turned on her tape recorder and low and behold, every other sentence clearly had the word "but" in it. Remember, I saw this in the first 10 minutes of our first session....yet, she needed to see it for herself in her own discovery. "I plan to do this, but..." "I think I need to do this, but..." "My boyfriend is helpful, but..." Self-discovery is a very powerful approach in counseling... because it forces the client to reevaluate everything...thoughts, feelings, and behavior. What we tell ourselves in truth or in lie shapes how we respond, think, feel, and behave.

A conceptual approach of Cognitive Behavioralism that I utilized was what I called the "AAA" approach.

A: awareness..."I Am" (Self Concept)

A: acceptance..."I Will" (Self Esteem)

A: action..."I Create" (Self Efficacy)

In this approach, the premise is that nothing will or can change unless one is "aware" of the situation, especially regarding oneself or an upcoming event. Again, one can not change what one is not aware of. So, time is devoted to exploring one's awareness or the lack thereof. This is a cognitive or mental step. In this, thoughts and beliefs are explored, faulty logic is exposed and challenged, alternative beliefs are evaluated as possibilities, and information gathering to fill in the gaps of knowledge is actively put into place. As our situations and as our world changes, our beliefs and our perceptions need to change also. It is a step in opening our eyes....perceiving who we are and that change is possible...and changing for the better. It is a step of cognitive reframing and refocusing. It is a time of hunger in reducing one's own ignorance. The previous college student comes to mind.

In the prior step, we have become more "aware" of ourself and of our situations. We also become more aware of how we hold ourself in our current state of unhappiness and ineffectiveness. Now the hard part....how does that new knowledge or awareness "sit" with me? Can I accept it? And if I can't or won't accept this new awareness, what is my cost?...the cost to others? Can I live with that? What does this new knowledge say about myself or my situation? Can I own it in my heart and truly come to accept it? Am I willing to change? Hence, the second and most important step is called, acceptance. The reason why it is the most important step is that if it can't be owned, much will not truly change in the short or long run. Although this too is a cognitive step....it is also a very emotional step. The feelings behind our self-discovery and how we respond to our world need to be worked through and owned....otherwise, self-sabotage is most likely to occur. Owning something is both a mental and emotional process. Just like being unaware sets oneself up for not being able to change via self-blindness, not being able to accept new knowledge sets oneself up for unwillingness to change. This step is often the toughest....for the person struggles for awhile in creating new changes in oneself...an internal process. It is a time to come to a certain truth, an accounting, of who we are and who we are to become. It is also a step of rechanneling the energy once wasted in ineffective pursuits and placing it where it needs to work for us. It is a step of emotional refocusing, where our emotions can now provide the energy to make these changes happen with less effort. It is a step in liking who we are becoming and embracing that change.

The last step is applying our new found awareness and our new willingness for change into creating new action....an external process. In fact, this is often the easiest step...for our new thoughts and emotional understandings can now provide a new drive to succeed in making things change in our life. Possibilities are now open. We see the choices before us. We have become emotionally invested once again...in a more positive and productive way. We change what and how we do things more effectively. We have removed our blinders, our mental roadblocks, our self-sabotage, and have rechanneled our energies. As a result, we are now putting new things into place and into proper perspective, trying new behaviors...exploring our creation...our new self. It is an exciting step...for things begin changing now because we have changed.

I use the term, "we", in much of the above because we, being the client and counselor, are working together to achieve the same goal....helping the client change and/or adapt better to his/her current life situations. It is also a form of counselor empathy...whereas the client emotionally understands that his/her counselor appreciates and understands his/her struggle. With change, we both celebrate.

In psychiatric nursing, various non-pharmacological approaches in assisting clients to cope better are often used....be it inpatient or outpatient. Much depends upon the cognitive abilities of said clients. Persons with limited cognitive abilities due to condition or medications may find this approach frustrating...and as such, may need to be tailored or not used at all. In some cases, the use of dialectical or instructional approaches may be the best approach to improve general or specific awareness. Group therapy can be a very powerful adjunct to Cognitive Behavioral therapy as peers often become emotionally invested in the progress of each group member...assisting each other in improved self awareness as a whole, providing a supportive community to cognitively and emotionally process new material, and most importantly, practicing new behaviors while eliciting constructive feedback from the group. Group members may also hold each group member accountable for individual and group progress.

In summary, Cognitive Behavioral therapy has been with us for quite some time. There are many approaches, from Ellis to mine....and there are many, many other cognitive behavioral approaches in between. No one approach works for all people. But, for many persons, many of these cognitive behavioral approaches do offer a second chance to "look inside and outside of their box".

Cognitive Behavioral Therapy

About Thunderwolf, MSN, RN

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