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Cognitive Behavioural Therapy in Bristol and Bath

A more detailed look at what it's all about....

What is Cognitive Behavioural Therapy (CBT)?

Cognition (to cognise) means “to possess knowledge or information about”. Re-cognise therefore means to know again. In practice the word cognition is also used to mean “to think” or to perceive (in a certain way). The way you cognise something is the way you perceive (or know) it. Cognitive Behavioural Therapy therefore is a therapy based on cognition (knowing) and behaviour. Human beings can think, feel, and behave irrationally and inflexibly. Here, the word “inflexibly” doesn’t imply being difficult or awkward, but refers to perceiving in a fixed way, without the possibility of using alternative perspectives. Having irrational beliefs, thoughts, and feelings can lead us to perceive the world through negatively skewed fixed perceptual filters and the resulting distorted cognition can make us feel (mistakenly) awful about ourselves, the world, and other people. In the same way that we can see things through “rose tinted spectacles” when we’re overly optimistic, we can also see things as being more threatening than they really are if our perceptual filters are negatively focused or distorted. Irrational and inflexible thinking creates disturbance at the emotional and mental level, because perceiving negatively means we find the World threatening, and this can inappropriately activate our fight and flight mechanism. This emotional and mental disturbance can lead to symptoms of anxiety, depression, anger, sexual dysfunction, phobias, social anxiety, loss of confidence, fear of the World, low self esteem, perfectionism, irritation, jealousy, obsession, compulsion, impatience with others….the list goes on. Cognitive Behavioural Therapy might be thought of at core then as learning how to be aware of anxiety causing perceptions and how then to use this awareness to maintain ongoing positive mental hygiene, thus reducing anxiety and all its associated symptoms. Once learned, it will be with you as a strategy for life. 

How does negative perception cause emotional disturbance?

CBT recognises that belief, thought, emotion, and behaviour all interact with, and affect, each other. What we believe affects the way that we feel and think. How we think affects the way that we feel. How we behave (as a result of thinking and feeling a certain way) then reinforces what we believe, what we feel, and how we think! Don’t worry, it’s not as complicated as it sounds. CBT is simply about learning to perceive and behave with flexibility, learning to minimise your levels of “reaction” (different from response), and to respond with an extended awareness of your options.

Essentially, we, as human beings, naturally tend to believe that if we feel something, or think something then it must be true. It’s simply not questioned, especially if our experience has told us that our perception is correct. If we live with a certain belief, we then go on to act and behave automatically as though that feeling or thought is absolutely true. In other words we assume that feelings and thoughts are facts, when in actuality they are often subjective interpretations of the facts based on our own personal beliefs and perceptual filters. Put simply, perceptions are by nature highly subjective (i.e not everyone would feel the same way about it). If it just so happens that the thought or feeling we are experiencing is negatively focused, then it usually creates fear, tension, worry, and stress. Though there may well be some truth to our assessment of the situation, a more objective evaluation will often reveal to us that a situation or perception is rarely as absolute as we perceive it to be, and that we actually have more options available to us than we are currently perceiving. These options can take the form of behaving differently, or thinking differently. Often we don’t perceive these options because in a stressed or un-resourceful state we can mistakenly “buy into” or “endorse” the feelings/thoughts/belief/s exactly as they present to us, and they can cause us to “react” rather than “respond”. Reaction is instinctive. Response is thoughtful and deliberate. Reacting can leave us feeling as though we had no other choice and this in turn can leave us feeling very stuck or emotionally/mentally disturbed. As an example we know that depression for instance is triggered partly by a feeling of “helplessness”. If our thoughts tell us “there’s no way out” then this perception can contribute to or sustain a depressed state. The assumption that “there’s no way out” is clearly only a perception, not a fact, and yet it can feel very true when there appears to be no evidence to the contrary. Obviously, believing we are eternally stuck in an unpleasant world (this is in fact what “there’s no way out” tells your subconscious mind about your life!), will be a very disturbing perception when we believe it absolutely as if it were a fact. If we can become aware of contrary evidence we’re on our way to finding a way out!

How does CBT work?

 CBT sets out look for evidence, both for and against the negative cognitions and then offers tools to go about integrating that evidence so as to think more critically (rationally) about our perceptions, thus reducing the level of disturbance such perceptions can cause. We then go on to learn to behave in accordance with our new more adaptive understanding, which over time, through repetition and continued thought/belief/behavioural adjustment helps us to feel differently (less stuck or disturbed). CBT does not talk about good and bad, or right and wrong thinking/feeling/behaviour. In fact CBT is deliciously free of such thinking. It is not a “moral” therapy. It doesn’t ask whether it’s “right” to think or believe a certain thing or not. It simply looks at whether it’s HELPFUL to feel or believe a certain thing or indeed to behave in a certain way. This is known then as adaptive (helpful), or maladaptive (unhelpful) perception.     

The Insights  

Paraphrased, Albert  Ellis’s insights (part of the foundation of CBT) state the following:

Insight 1 – How you feel is mainly determined by the way you think.  – This notes that the beliefs you carry and action with feeling become your living emotional reality.

Insight 2 – You become distressed when you endorse your own irrational beliefs – This notes that those beliefs that create unpleasant feelings will distress you when you “buy in” to them without challenging the assumptions by seeing different options of thinking and perceiving.

Insight 3 – Be kind to yourself. You, like many people, can think irrationally so don’t judge yourself too harshly – This notes that CBT is not a self blame exercise…everyone thinks irrationally sometimes…it’s not right or wrong…so one can be kind to oneself whilst adjusting thoughts and behaviours appropriately for easier feelings.

Insight 4 – You have to make a sustained effort to recognise and challenge your irrational thoughts- This notes that effort is required over a sustained period of time to make the above adjustments. Years of ground- in negative perceptions take time to adjust! Patience and persistence is necessary but there is a pay off!  

The Therapy

Typically, CBT is a longer term therapy than Solution Focused Brief Therapy. It usually lasts anywhere from about six to thirty weekly or fortnightly sessions.  Some CBT therapists work to a sixteen session standard. This is a “one size fits all” approach which means that everyone knows where the therapy begins, continues, and ends, giving a nice clear focus to the client and therapist alike to complete the therapy. As with all good therapy, CBT is goal oriented, reflective, methodical, evidence-based, and time-limited. In plain English this means we want to see the results and we want to reflect as we go on each stage of the progression towards wellness and understanding. You can think of it as moving methodically towards symptom resolution in stages of understanding and application. CBT is very much a learning and brain re-training process. Central to the CBT approach is the understanding of exactly HOW we go about thinking irrationally. When we can identify skewed perceptions as they arise within us, we are much better equipped to stop any internal endorsement (buy-in) of irrational disturbing perceptions before they occur. The following describe some of the best known perceptual distortions that occur in thinking: -

All or nothing thinking

This is “absolute” thinking. Here, if something is less than perfect, then it’s seen as all bad! If we can’t do it/ have it all, then it’s not worth trying. This can create feelings of being overwhelmed. Chunking down is the process whereby we tackle things in bite-size chunks, which often makes them appear much more manageable, and recognise too that maybe we can do SOME of it if not ALL of it.

Over-generalisation

Characterised by using the words "always" or "never". This one creates feelings of being consistently defeated and creates a negative feeling about the World, Self, and Others. It is RARELY based on FACT.  To overcome over-generalisation we look for exceptions to these internal assertions.

Mental filter  

This filter involves filtering out whatever doesn’t “fit” ones beliefs, and looking ONLY for evidence that supports your way of seeing things, even if that’s purely negative. Usually this means dwelling on a single negative detail and excluding all else! Extreme fundamentalism is an easily recogniseable symptom of this kind of thought distortion, and good evidence to remind us how deep it can run in some people!

Discounting the positive

Can you accept a compliment? Can you give yourself a pat on the back for something you did well? This one involves being able to discount the twenty people you helped today because one person had a complaint! (justified or not). You reason that the rest don’t count because anyone could have done your job and they were just being nice because they felt sorry for you anyway! Situationally too, we can discount the positive when one thing isn’t right.

Jumping to conclusions

We already KNOW what they meant with that comment! Do you? Really? Did you check? This is the “mind reading trick” and can be so useful in reminding yourself how hostile the World is (even when your friend was innocent!), because it’s great for not having to see that everyone is NOT out to get you! If you already KNOW what someone means then there’s no possibility you might have misunderstood right? Angry people can go a whole lifetime doing this one….Never knowing that most people are quite nice and quite like you when you speak to them kindly.

Negative Forecasting

Forecasting that the future (events and general) will be awful is a massive cause of stress. Since your brain is the most powerful future experience rehearsal machine in the World, your poor old (not so logical) subconscious mind gets very worried indeed when you negatively rehearse the future as a frightening destination! When you tell yourself that things will turn our badly, you create fear and stress. Then, because you’re so stressed and fearful, your performance drops; everything turns out badly, and you say “See! I told you so!” Then whole cycle then begins again, but reinforced because it did in fact go as badly as you imagined. Ironically that’s because you imagined it going badly first!

Magnification or maximisation

Exaggerating your problems and shortcomings so everyone (and you) knows how helpless or useless you are. If you’re already useless then at least you can’t fall any further right? Magnifying your negative qualities is the surest way to stay in self judgement and out of learning to love yourself …warts and all. Also magnifying your problems makes your life look to you completely unmanageable and creates feelings of hopelessness. Still at least if you’re hopeless there’s no point trying right? It could be thought of as being in “victim” mode. Maximisation is often connected therefore to a fear of success or paradoxically a fear of failure. Maximisation creates inaction. It encourages you to remain stuck and disempowered. The subconscious mind often prefers the familiar but unpleasant to the unfamiliar and potentially more adaptive. Familiar is considered safe even if it hurts!

Catastrophising

This is like magnification but comes with a whipped cream topping of drama. Catastrophising means seeing negative events, people, or mistakes as absolutely and quite unbearably awful; it is often also therefore called “awfulising”. This is a very important distortion to understand in CBT because how we “choose” to see event’s dictates how we feel about them subjectively. We all have to deal with unpleasantness sometimes. It’s MUCH easier if we can learn to deal with it courageously and with dignity and not like a drama queen or a “victim” (poor me). Catastrophising is perhaps the most direct way to ensure you directly and needlessly disturb yourself!

Minimisation

Playing down your strengths – No matter what the evidence is that you have good qualities…you just can’t/won’t see/believe it!

Emotional reasoning

I FEEL it therefore it MUST be true. Feelings are facts and to hell with the truth!

Inflexible language.

Should, must, ought to, have to etc statements – Musterbatory  or "Mind Menace" language.  

When you say something “should” be a certain way, you are guaranteed to feel disturbed when it’s not! The same goes for have to, ought to, must etc. This language can be directed towards yourself and is even more powerfully disturbing when directed towards the world or others! “Should” is the surest way to ensure you don’t. “Should” is also the surest way to get someone else into a defensive stance. “Shoulds” can be easily replaced with “I’d prefer”, or “I’d like to”. Stop “shoulding” all over yourself! Can’t is pretty inflexible too! 

Negative labelling

This refers to labelling self or others as exclusively negative. So rather than knowing that no-one is perfect we can over-generalise a person’s behaviour or thinking as bad and label that person a failure or a jerk. This is inflexible thinking and can be directed towards self, creating terrible feelings of low self worth!

Personalisation and blame

A big one in CBT. We personalise that which is often out of our control. When an event happens that is beyond our control (illness. missed opportunities etc) we blame ourselves. This makes you feel rotten about yourself! Perfectionism can often fall into this category.

Blame is the opposite of course where we are unwilling to assume responsibility for our lives and behaviour and thus never arrive at a place of healing because how can we heal it if we don’t own it? Blaming also makes you mad at everyone else (creates anger) and blocks solutions in a big way!

The History of CBT

Although CBT has been influenced by Buddhism and Science alike through the years, perhaps the most interesting individual historical contributors are Marcus Aurelius, Epictetus, and Immanuel Kant.

Marcus Aurelis (121-180AD) was a Roman Emperor. He was the author of a classic philosophical text called “Meditations”. Centrally he is quoted as saying “If you are distressed by anything external, the pain is not due to the thing itself but to your own estimate of it; and this you have the power to revoke at any moment”. This idea that we can choose how to respond to situations and events is of course front and centre to CBT.

Epictetus (55-135AD) was a slave and endured great hardship. His “master” would often torture him and on one occasion, during a leg twisting torture session, Epictetus warned his master that the leg would break. The message was not heeded and the leg broke, leaving Epictetus lame. Epictetus is quoted: “Some things are up to us and some things are not. Our opinions are up to us, and our impulses, desires, aversions – in short, whatever is our own doing. Our bodies are not up to us, nor are our possessions, our reputations….that is, whatever is not our own doing” 

Although this message is perhaps less relevant to most people’s situation today, the central theme, that being that there are factors in life beyond our control such as other people, and their opinions, remains highly relevant to CBT. In essence there are many things we can’t control in life, but he notes we can choose to control how we respond to those things.

Immanuel Kant (1724-1804) – Immanuel Kant basically proposed that objectivity (the real world) is ultimately imperceptible to the individual. He explained that all experience is filtered through subjective filters, named schema. This also is central to CBT. In understanding that what we experience is an “interpretation” of events rather than a “fact”, we can easily find our way back to the CBT based understanding that what we “feel” (our filtered interpretation) about something doesn’t always match the “facts” of the situation.

The Process.  

So now, you can probably begin to see how CBT works? The problem is that we are often in the habit of thinking in these distorted ways without conscious awareness of doing so. CBT uses many different techniques to bring a new awareness to these patterns. A discussion of the techniques used are beyond the scope of this article, but a central technique is to use a “Thought Record”. A thought record asks you to record exactly where you are, who you’re with, and what you are doing at the moment that your mood shifts from positive to negative, and then to write down your thoughts exactly as they occur at that moment. Having identified those central “disturbing, maladaptive” thoughts and  beliefs, we can go about providing more adaptive perspectives. This process is collaborative, meaning that the therapist guides you towards a better understanding of how you may be distorting your perceptions and we work together then to create new more helpful perspectives that you can buy into with feeling. Alongside this, we work on core beliefs, because if a core belief is negative then it can create LOTS of negative thoughts in many different situations. A core belief that says essentially “I’m no good at anything” will affect everything you do negatively. Using thought records and other CBT tools, we can quickly trace back to the roots and find the core belief. 

There are many tools we use in CBT including (but not limited to): -

  • Reviewing Thought Records (Records you have kept of the thoughts that accompany disturbed feelings). Using these to identify the offending thoughts and together creating more positive perspectives for future disputation of such thoughts. 

  • Goal Setting Sheets - Looking at ways forward through the difficulty and breaking that process into small manageable chunks whilst addressing any obstacles that may appear to stand in the way of success.

  • Looking at "Mind Talk Menaces" and how beliefs about how things "should" or "must" be can contribute to a sense of disempowerment and emotional arousal, especially where these "shoulds" and "musts" are not congruent with the way things really are. 

  • Hypnothesis Testing - Questioning to see whether a belief is 100% true or whether there are positive exceptions. 

  • Reviewing Activity Diaries to identify patterns in activities that are creating emotional disturbance. 

  • Scaling Tools which help us to identify areas of life dissatisfaction generally. 

  • Objectifying Dispassionate Thinking (Looking at alternative ways of viewing things which are less emotionally arousing). 

  • Behavioural Experiments - Setting behavioural experiments between sessions and recording what actually happens as opposed to what is believed might happen, thus creating an evidence based understanding that outcomes are frequently more positive than expected. 

  • Excess and Deficit - Identifying what we need to do more of and less of and creating an action plan. " 

  • Increasing Low Frustration Tolerance - Helping you to be more able to deal with difficult thoughts/feelings without becoming overwhelmed. 

  • Releasing Negative Feelings. 

  • Teaching you to relax properly and deeply. 

  • Identifying "core beliefs" and helping you to change those beliefs which are disturbing and cause negative automatic thoughts about World, Self, and Others. 

  • Controlled Worry Period Contracts with self.

  • Cost-Benefit Analysis - Help in viewing important decisions rationally and objectively. 

  • Exploring your personal "rules" and what happens when people don't stick to them. Examining whether your rules are reasonable and if so, moving on to: 

  • Assertiveness Training - Learning to create personal boundaries, communicate your "rules" effectively, and say "No" where appropriate. 

These processes give great structure to the process and allow us to evaluate our successes and accomplishments as we gain them, thus giving you increasing confidence and evidence in your ability to live from new beliefs and step into empowerment.

Cognitive Behavioural Hypnotherapy

Cognitive Behavioural Hypnotherapy makes total sense! It always has to me. Firstly a few snippets of research for you:

Smith et al. (1984) pooled the results of 475 controlled studies into the efficacy of different modes of therapy. The results showed that Cognitive Behavioural Therapy, systematic desensitisation, and hypnotherapy performed “better than average” in achieving therapeutic improvement, where average was defined as the mean outcome of all therapies studied.

The international journal of Clinical and Experimental Hypnosis 2007 conducted a study of 84 depressed persons using 16 weekly treatments of CBH versus CBT alone. The results showed that CBT combined with hypnotherapy produced a greater improvement in anxiety by 5%, hopelessness by 8% and depression by 6% than if CBT were used alone, demonstrating clearly that CBH could be highly effective as a treatment model.

The British Medical Journal published studies in 2005 finding that in one study of 30 people presenting with severe IBS, that treatments using hypnotherapy alongside CBT were more effective than in the non-hypnotherapy control group. The 15 patients from the hypnotherapy group were followed up over the next 18 months and it was found that all patients had remained in remission.

These results don’t surprise me at all. The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health. CBT is recommended by NICE as an effective evidence based therapeutic methodology. In plain English this means it’s mainstream (it is used within the NHS) and has been proven in trials as highly effective.

The Royal College of Psychiatrists tell us:

 http://www.rcpsych.ac.uk/mentalhealthinformation/therapies/cognitivebehaviouraltherapy.aspx

How effective is CBT?

§         It is one of the most effective treatments for conditions where anxiety or depression is the main problem

§         It is the most effective psychological treatment for moderate and severe depression

§         It is as effective as antidepressants for many types of depression

In short then, CBT is effective, and research is showing, what we as practicing hypnotherapists have always known; that cognitive behavioural hypnotherapy is even more effective. Let’s have a look at why.

Why Cognitive Behavioural Hypnotherapy?

We know that negative thinking arises from what are known as “Schema” or “Schemata” (plural schema). Schemata is the term used to describe the perceptual filters I have been talking about. Schemata are based on core beliefs. Hypnotherapy has always been about helping people to change their core beliefs by communicating directly with the unconscious mind. You can find plenty of information about this on my website, but essentially, we know that we can change core beliefs much more quickly and to a greater depth when we go straight to the source. That is to say, using hypnotherapy, we can communicate these more adaptive cognitions directly to the unconscious mind, thus bypassing the usual “resistance” of the conscious mind. The unconscious mind of course is where your core beliefs reside. This is the central computer from which all thinking, feeling, and behaviour springs. Since CBT is primarily a conscious mind technique, we have a major advantage when using CBT combined with hypnotherapy, because conscious mind adjustment is a slow process. It’s effective, and often necessary, but it’s like a drip feed when it comes to relaying information back to the unconscious. The message of change is only slowly absorbed when you work purely at the conscious mind level, and then only by persistence and repetition. Since hypnotherapy operates at a much more visceral (subconscious) level, we can amend belief systems quickly, and these belief systems are at the core of your thinking.  Change the belief at the unconscious level and you simply FEEL, THINK, and BEHAVE differently. Therefore, whilst CBT can give great structure to the therapeutic process, hypnotherapy can help to deliver the necessary perceptual adjustments much more directly. In many ways then the two therapies compliment each other perfectly. Having access to both therapies also places us at a considerable advantage when it comes to addressing the individual components of a difficulty, which are often multileveled.

A Fictional Case Study

To understand how each approach can aid in a typical therapy let’s have a quick look at an example. Suppose Client A (Let’s call him Ben – he is pure fiction!), arrives with generalised anxiety. Upon further investigation we learn that Ben also has an irrational fear of balloons and spends a large part of every day working as a delivery driver worried that a child may turn the corner carrying a balloon. He also fears that one of the shops he delivers to may have inflated balloons on their premises. CBT could take care of this difficulty, but it would probably average at least three or four working sessions of graded exposure tasks, alongside continued adjustment of thinking and behaviour. With hypnotherapy, using NLP techniques, we would expect to be able to quickly desensitise and re-frame this difficulty in perhaps one or two sessions. We will usually create a more thorough recovery with this type of difficulty using hypnotherapy because an irrational fear of balloons is a subconscious mind response that will respond beautifully to the techniques hypnotherapists use to de-sensitise phobic templates. Separately, Ben also worries that the people in the shops he delivers to don’t like him. He is concerned that a customer might make a complaint about him and that he may lose his job as a result. Using CBT techniques we could have Ben record his thoughts each time he feels this way, and in so doing, we could then work together to examine the evidence for and against this possibility. With a rational objective evaluation we will discover that these feelings and thoughts are not supported by any strong evidence, but are in fact part of the anxiety pattern that Ben suffers with generally. Using CBT we would teach Ben to start behaving as though these perceptions are just intrusive negative thoughts and feelings instead of behaving as though they were a true reflection of reality. If we were to discover evidence that people were unpleasant to him, we would help him re-frame that as their problem, not his! Over time, Ben will gain his confidence and learn to notice that people are usually responding to him in positive ways which results in him being calmer and feeling better generally. 

We can use hypnotherapeutic mental rehearsal to have Ben imagine himself being calm at work, and we can create positive post-hypnotic suggestions that will be activated when he arrives at the delivery which help Ben to maintain his positive mood and walk with confidence etc. This new perspective and understanding sends a message back to that core belief that Ben does NOT endorse it. This also tells the brain that the negative belief is not true. It is only when we endorse these feelings that they remain true for us. When we dispute them they lose their power over us. Over time then the core beliefs adjust rather than Ben himself having to adjust (by remaining anxious) to the core beliefs.

So, with this nicely black and white example (rarely are things quite as black and white in practice!) we can see why having access to both therapies helps and how each therapy can reinforce the other. CBT gives structure. Hypnotherapy quickly deals with subconscious mind resistance to assuming new perspectives. This process is highly flexible and can be used to address almost any emotional difficulty. What makes it particularly powerful is that it is structured and logical, whilst encouraging both subconscious and conscious mind adjustments, essentially covering all the bases. When the conscious mind and the subconscious mind are in agreement then there is no conflict and change can be surprisingly easy.

About me and CBT

I am primarily a hypnotherapist. During my career as a hypnotherapist I have always incorporated basic CBT understanding into my overall approach, so CBT is not new to me. However, I went on to undertake further formal training in CBT to extend my skills, earning my Diploma in Cognitive Behavioural Hypnotherapy. This diploma is accredited by the NCFE, an external national standards examination board to NVQ4 level. This is the equivalent of a higher national diploma (HND) or first year degree, and to earn this diploma you must demonstrate a high standard of competency. (Click here to learn what an NVQ is). CBT practitioners who offer CBT as their primary therapeutic model undertake extensive training purely in CBT, and are usually members of the associated CBT professional associations. For this reason we make the distinction that I am a Hypnotherapist with some formal CBT training rather than a CBT Therapist.  Nonetheless, as I hope I have explained, CBT and hypnotherapy work beautifully together, and my formal CBT training means that I have a solid working knowledge of the principles and applications of CBT.

As a general rule, I will take a hypno-therapeutic approach to most difficulties which incorporates CBT principles/application as standard where appropriate and helpful but if you prefer to use "pure" CBT (no hypnotherapy) then just let me know and we'll do so.

If you would like some help with a difficulty, please do feel free to contact me for a free consultation.

If you would like to book a consultation with a view to starting treatment in Bristol or Bath you can contact me, call on 0117 904 4504 or email me.

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