Cognitive Behaviour Therapy
Cognitive Behaviour Therapy (CBT) is a widely practised and evidence-based therapy which focuses on identifying and working with negative thought patterns and behaviours that contribute to emotional distress and mental health issues. It is based on the idea that our thoughts, feelings, and behaviours are interconnected, and by changing our thoughts and behaviours, we can effectively manage and alleviate psychological challenges and improve mental health and wellbeing.
Key principles of CBT include:
- Collaborative approach: Therapists and clients work collaboratively to set goals, identify negative thought patterns and develop strategies to challenge and change them.
- Goal oriented: CBT is typically short-term and goal oriented, focusing on specific challenges and helping individuals develop practical skills for managing them.
- Behavioural activation: This involves identifying and modifying behaviours that contribute to or maintain emotional difficulties. It encourages engaging in positive mobilising or up-regulating activities and breaking the cycle of avoidance.
- Exposure and desensitisation: CBT is often used to treat anxiety disorders by gradually exposing individuals to feared situations, helping them become less anxious over time.
- Exposure and response prevention (ERP): This is a core component of CBT for OCD. ERP involves gradually exposing the individual to anxiety-provoking stimuli or thoughts while preventing the compulsive behaviours used to reduce the anxiety (or distressing emotion). It helps reduce the individual's distress and the compulsion to perform the rituals as they learn the feared outcomes are unlikely or manageable.
- Out of session work: Clients are often given tasks to practise between sessions, such as journalling, thought records, or engaging in specific behavioural exercises.
- Cognitive restructuring: CBT helps individuals recognise and challenge distorted or irrational thoughts, often referred to as cognitive distortions. By examining the evidence for and against these thoughts, individuals can replace negative beliefs with more balanced and realistic ones.
CBT has been successfully applied to a wide range of mental Health issues, including depression, anxiety disorders, PTSD, OCD and more.
While I use aspects of CBT in my work with clients, I have found the following third wave therapies to offer more opportunity for transformational and lasting change.
Schema Therapy
Schema therapy integrates elements of cognitive behaviour therapy, psychoanalytic theory, attachment theory, and experiential techniques. It was developed in the 1980s and 90s by Jeffrey Young and colleagues to offer psychological support by addressing deep-seated patterns of thoughts, emotions and behaviour known as "schemas". Schemas are emotional beliefs that individuals develop in childhood, adolescence and early adulthood. They become the 'lenses' through which we see ourself, others and the world and influence our interactions and experiences throughout life which can impact our mental health and wellbeing.
Key features of schema therapy include:
- Identifying schemas: The therapy aims to identify maladaptive schemas - negative and self-defeating beliefs about oneself and the world. These schemas often stem from early experiences and can lead to persistent emotional difficulties.
- Schema modes: Schema therapy recognises that individuals can shift between different modes which represent distinct, emotional states and coping strategies. These modes include child modes (e.g. vulnerable child, angry child, impulsive, undisciplined child & happy child), maladaptive coping modes (e.g. avoidant/detached protector, compliant surrenderer, perfectionistic overcompensator etc), critic modes (e.g. punitive critic, demanding critic etc), and healthy adult mode.
- Limited reparenting: A central element of schema therapy which involves the therapist providing nurturing and corrective experiences to address and meet emotional needs from childhood, fostering healing and emotional growth.
- Cognitive and behavioural techniques: Schema therapy employs techniques to challenge and reframe negative beliefs and schemas and encourages new behaviours. However, importantly it includes experiential techniques that help clients connect with and process emotions related to their schemas.
- Imagery rescripting: This way of working involves reimagining and rescripting past experiences in a more supportive, protective and empowering way where childhood needs are met which can help rewire and challenge negative emotional schema associations.
- Mode work: clients are helped to identify, recognise, and 'give voice' to modes, to understand and build confidence managing different 'parts'. This way of working helps to process and address conflicts which can arise between different modes. Therapy looks to strengthen the role of the healthy adult side to become the inner leader responding and managing other modes and creating conditions for needs to be met.
Schema therapy is often used to treat complex and long-standing issues and life patterns which have not responded well to other treatments, such as complex personality difficulties, chronic or recurrent depression, chronic anxiety and complex trauma (CPTSD). It aims to address the deep-seated roots of emotional distress and promote healing, self-awareness, and lasting change. Due to its comprehensive nature, schema therapy is typically a longer-term therapy compared to some other therapeutic approaches.
Compassion Focused Therapy
Compassion Focused Therapy (CFT) is an evidence-based therapy developed by psychologist Professor Paul Gilbert and colleagues. It is grounded in the principles of evolutionary psychology, neuroscience and CBT. CFT aims to improve mental health and wellbeing by developing greater self-compassion and alleviating emotional difficulties, particularly those related to shame, self-criticism and low self-worth.
Core principles of CFT include:
- Compassionate Mind Training: CFT focuses on cultivating self-compassion, compassion for others, and being able to receive compassion from others. This involves learning to treat oneself (and others) with kindness, understanding and acceptance even in the face of difficulties or mistakes.
- Understanding the mind: CFT teaches individuals about the different emotional systems in the brain, including threat-focused, drive-focused and soothing/affiliative-focused systems. This understanding can help individuals make sense of their emotions and reactions and work towards creating a healthier balance of the systems.
- Addressing self-criticism: CFT can offer psychological support by reducing the negative impacts of self-criticism and self-blame, which often contribute to mental health challenges like shame and self-hatred, anxiety, depression, eating complexities and other coping strategies etc.
- Mindfulness and imagery: Techniques such as mindfulness and imagery are used to cultivate a compassionate mindset and help individuals connect with feelings of safety, warmth and care.
- Client-therapist relationship: The therapeutic relationship is characterised by empathy, warmth, and a focus on creating a safe and non-judgemental space for the client to explore, heal and learn.
CFT has been effectively used with various mental health concerns, including depression/post-natal depression, anxiety, social anxiety, anger, trauma, eating disorders and chronic pain. It aims to help individuals shift from self-criticism to self-compassion, fostering emotional resilience and wellbeing.
Lotus flower
Mindfulness-based approaches
Mindfulness is an attentional practice and state of awareness that involves paying deliberate and non-judgemental attention to the present moment. It involves being conscious of the workings of the mind without feeling that we have to react to thoughts, feelings or urges that may arise.
Key aspects of mindfulness include:
- Present moment focus: Mindfulness involves directing your attention to the hear and now, rather than dwelling on the past or worrying about the future.
- Non-judgemental awareness: Mindfulness encourages observing thoughts, feelings, and sensations without labelling them as good or bad. This helps reduce automatic reactions and promotes a sense of acceptance.
- Open awareness: Mindfulness involves being receptive to whatever arises in your experience, whether it is positive, neutral, or negative without trying to change it.
- Observing thoughts and emotions: Instead of getting caught up in thoughts and emotions, mindfulness teaches us to observe them as they come and go, recognising that they are temporary mental, physiological events.
- Mindful breathing: Focusing on the breath is a common mindfulness practice that helps anchor attention to the present moment.
- Body scan: This practice involves bringing awareness to different parts of the body, noticing and differentiating sensations and areas of tension or relaxation.
- Mindful activities: Practising mindfulness while engaging in everyday activities such as eating, walking, or washing dishes, helps bring a heightened sense of awareness to routine actions.
Mindfulness is often cultivated through meditation and mindfulness exercises. It has been shown to have various psychological and physiological benefits. It has an evidence base in reducing ruminative thinking and stress, improving focus, enhancing emotional regulation, helping us to choose how to respond to internal or external events, and promoting overall mental health and wellbeing. Mindfulness practices are commonly integrated into mindfulness-based therapies and psychological support.
Polyvagal-informed approaches
Polyvagal Theory (PVT) was developed by psychologist and neuroscientist Professor Stephen Porges. It emphasises the role the autonomic nervous system (especially the vagus nerve) plays in regulating our behaviour and health. Polyvagal theory helps us understand how our brain & body work together to respond to threats detected in our environment, relationships or in our bodies/mind and how cues of safeness can help shift us out of these defence-based states.
In each of our relationships and environments, the autonomic nervous system is 'learning' about the world and being toned towards habits of protection or connection. While early experiences shape the nervous system, ongoing relationships and experiences can also reshape it.
Key concepts of Polyvagal Theory include:
- Autonomic Nervous System (ANS): The theory emphasises the role of the ANS in responding to threats and danger and promoting safety. It identifies three hierarchical phylogenetically ordered neural circuits - i) the ventral vagal complex (a social engagement system), ii) the sympathetic nervous system (a fight and flight system), and iii) the dorsal vagal complex (a collapse/shutdown system).
- Neuroception: Neuroception is the unconscious process through which our nervous system evaluates whether a situation is safe, dangerous, or life-threatening. This process affects our physiological and emotional reactions.
- Social Engagement System: Our mammalian evolved design necessitated care giving and care receiving and living in groups thereby increasing our chances of survival as a species. The ventral vagal complex is associated with the social engagement system which promotes connection, social interaction and emotional regulation. Disruptions in this system can lead to difficulties in social interactions and emotional regulation.
- Trauma and stress reactions: Polyvagal Theory helps explain how trauma and stress can impact the ANS, leading to various reactions such as fight, flight and collapse or shutdown.
PVT-informed approaches use these concepts to guide therapeutic interventions:
- Regulation of the ANS: PVT-informed therapy focuses on helping individuals regulate their ANS responses through techniques that promote safety, connection and self-regulation.
- Social engagement and connection: Therapy aims to support the development of healthy social engagement responses, improve social interactions, and foster a sense of safeness in relationships.
- Mindfulness and self-awareness: Practising mindfulness and cultivating self-awareness can help individuals recognise their autonomic reactions and develop strategies for responding to them.
- Trauma-informed care: PVT-informed approaches are particularly relevant in trauma therapy because they address the physiological underpinnings of trauma responses. This important in de-shaming defence reactions and can help individuals tune into how their body is trying to help them and what can be done to build a sense of safety.
PVT-informed treatment and psychological support is used in various therapeutic approaches, including trauma therapy and interventions aimed at improving emotion regulation, social skills and overall mental health and wellbeing. It is especially relevant in understanding the biopsychosocial basis of emotional and relational challenges.
Image of brain & nerve pathways in the human body.