Cognitive behaviour therapy
CBT was developed by the American psychiatrist Aaron Beck (born 1921), initially as a treatment for depression. As the psychologist Gillian Butler has written, CBT is ’based on the recognition that thoughts and feelings are closely related. If you think something is going to go wrong, you will feel anxious; if you think everything will go fine, you will feel more confident.’ So CBT therapists work with their clients to identify and evaluate negative thoughts and the unhelpful behaviours that often result.
CBT isn’t a narrowly prescriptive programme. Exactly how it is applied to anxiety (or indeed any other problem) depends on the nature of the disorder and the person being treated. Treatment is based on the construction of detailed models showing how a disorder is caused, maintained, and overcome. As more is discovered, the model is updated and the therapy evolves accordingly.
(Incidentally, one of the problems commonly treated with CBT is hypochondriasis, which is the fear that one is suffering from a serious illness. Hypochondriasis is often referred to as ’health anxiety’. The psychiatric classification systems, however, don’t categorize it as an anxiety disorder, though many experts believe it would be more logical to do so.)
At the core of CBT for anxiety is the idea that fear is a product of interpretation. We are frightened not because something awful is happening, but because we believe it will happen in the future. To overcome your anxiety, you must test out your interpretation by experiencing the situation you fear. And you must do so without adopting any of the safety behaviours you would ordinarily use in order to cope. If you can do that, you will discover that your fears are misplaced.
For example, a person suffering from OCD who fears contamination would be encouraged to seek out dirty environments, and to resist the compulsion to wash repeatedly afterwards as they would ordinarily do. An individual with panic disorder might be asked to visit a place they would usually avoid and to stay there even when they feel the sensations of panic. If they can ride out the panic, rather than fighting it, they’ll find out that what they dreaded — a heart attack, perhaps, or fainting — didn’t occur. And a person with social phobia might be shown videos of themselves in a social situation, once when using their safety behaviours (avoiding eye contact, for example, or carefully rehearsing everything they say) and once without those safety behaviours. They can then see that their safety behaviours aren’t in fact helping. They’ll probably also discover that they come across much better than they had imagined. Below we describe CBT for two problems in a little more depth.