How Cognitive Behavior Therapy Works – Interview
Ramona Interviews Helen Turano About CBT (Transcript)
Ramona: I am Ramona, and welcome to Ramona Interviews. With me in the chair today is Helen Turano. Now, she’s a Cognitive Behavior Therapist, and this is going to be a really interesting show, so I would like you to stay with us.
Helen: I’ll tell you a little bit about what CBT is like and how it’s different than regular talk therapy. If you got a regular “talk therapist” as a client, you are the one who goes in and starts talking. Some “talk therapists” are more interactive than others, but basically, the client directs the conversation. Now in CBT, we plan an agenda. First we check in with the client to get a measure of how depressed or anxious they are, and then we ask about their agenda items. We want the client to decide what they want to talk about this week, what’s most important, but the therapist will also have some agenda items because a CBT therapist does a lot of teaching.
We know a lot about how the mind works. We know a lot about skills and techniques that the client can learn. Our goal is to teach the client to be his or her own therapist. CBT is time limited. People sometimes have the impression that it’s very short. It’s not necessarily. I would say the average client that we see has more than one problem, so it’s not necessarily all done in six or eight sessions, though it that it can be.
Eventually, we’ll wind up the therapy, and the client may come back if they wish for booster sessions to make sure they don’t lose their skills.
I’ve made up an example of a nonexistent client. She is a 30-year-old single woman. She has not been in a relationship for years since her last partner broke up with her. She has not been dating at all. She’s withdrawing from friends, and recently, she has been passed over for a promotion at work. Over the last year, she has gained 50 pounds.
I would start by finding out what kind of thoughts she’s having that are contributing to her depression. One of the thoughts is probably why she’s withdrawing from friends, something like, “Nobody likes me because I’m uninteresting and unattractive.” Of course, I wouldn’t assume this is her thought. I’d find out what her thought actually is. There could be another thought that, “It’s unfair that I was passed over at work, ” and maybe some self-blaming around that. Let’s also look at behaviors that are contributing to the problem. This client is avoiding, obviously. She’s avoiding talking to her friends. She’s avoiding dating. Being passed over for promotion happened six months ago. She hasn’t done anything about changing her work situation, and she is eating too much every day when she gets home from work.
I sit with the client, and I talk with her about her beliefs. For example, “I’m uninteresting and unattractive.” Is there any evidence for that? Did she have friends calling her before she stopped calling them? Does she have a few still calling? Has she had relationships in the past? Is the thought that “I’m uninteresting and unattractive,” realistic, or could there be some other explanation for why things aren’t going well with right now?
Let’s also think about the avoidance. People often think that when you start to feel better, you start changing your behavior. Now, we’ve really proven that if you changed your behavior, you’ll start to feel better. This is difficult. This is why people need therapists, right, because it’s pretty hard to just change your behavior just like that. We work with the client. “What would be an small thing that you could do this week, to change your behavior?”
Now, it might be that this client could could say “Hi ” to anybody else who lives in her building that she sees on the way out. This would be instead of running out the building with her head down, which is what she typically does. If she says “Hi” to people, they might say “Hi” back, and that might undermine some of her thinking and in itself is a step forward. We’d also challenge doing nothing about her job dissatisfaction. Now, negative thoughts are not necessarily distorted. Maybe this woman’s boss really does prefer another worker. It’s a small business, and the other worker is related to the owner. Or maybe if this woman behaves differently at work she will get promoted next time. We could look at that and tease it out.
The next thing that we would do is we would look at her eating. It seems like this woman falls has a pattern of yo-yo dieting. She believes that she eats healthfully during the day, but she actually doesn’t eat enough. This is a woman who doesn’t eat breakfast and has a salad and a piece of fruit for lunch. Of course, when she walks in the door after work, she is absolutely starving, and her resistance to bingeing on all kinds of stuff is very low. We would probably recommend that this woman see a nutritionist and come up with a plan to eat three meals and two snacks everyday.
This brings us to a very important part of CBT, which is “homework”. A typical homework would be filling out something called a “thought record”. I make a chart, and I write across the top of the paper, “Event”, “Thought”, “Feeling”, and “Action”. During the week, at some time when the client has negative feelings, she’ll note down what her feelings are, and she’ll try and figure out the thoughts that go with them
For example, feeling sad because nobody have called her might well go with the thought, “Nobody likes me.” Often there’s a triggering event like arguing with someone or a friend getting married. After she writes down the event, the thought, and the feeling, she’d write down what she did next. What we’re trying to do here is help the client understand, “Oh, on Thursday afternoon, I went home. I wasn’t really hungry because I had plenty to eat that day, but I was feeling lousy because my boss criticized me, and I thought that I was no good at anything. I went home and ate a large bag of chips.” Then we move on to learning new skills to tolerate negative feelings and change what she actually does.
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