Tara Haddad | Junior Editor of Opinions

Cognitive Behavioral Therapy (CBT) is widely recognized as a thoroughly researched and highly effective treatment for both psychiatric and non-psychiatric disorders. During a recent conference held on March 7th by the MINDS Student Network and the AUB Psychiatry Interest Group, Dr. Nadia Tina Dandan, an Adult Clinical Psychologist at AUBMC, and Dr. Tala Diab, a Research Fellow at AUBMC, delved into the principles, applications, and importance of CBT, while also examining its clinical effectiveness and practical application through real-life case studies. 

Dr. Dandan introduced the discussion of CBT by revisiting its roots, specifically highlighting Aaron Beck’s seminal role in the development of the treatment in the 1960s. Since its inception, CBT has undergone refinement, evolving from its initial application in treating depression to encompassing a broad spectrum of psychiatric disorders including depression and anxiety, as well as non-psychiatric conditions such as obsessive-compulsive disorder (OCD), phobias, and panic attacks. Regardless of the type of disorder, the bulk of the work is focused on changing the patient’s behavior and how they think. Dr Dandan touched on its core principles, stating that an individual’s problems are partly based on faulty ways of thinking and learning patterns of unhelpful and maladaptive behavior, CBT supports patients in unlearning these harmful patterns. 

While CBT offers clinically backed treatments, such as exposure-based treatments for OCD and systematic desensitization in the treatment of phobias, the question arises, how can we discern when it’s appropriate to suggest CBT as a treatment option? Dr. Dandan emphasizes that it’s not simply a matter of a yes or no decision; rather, it entails a process involving multiple considerations such as the psychologist’s clinical judgment and their assessment of symptoms. Through the ability to draw on knowledge of CBT models and their own clinical experience, the psychologist can select and skillfully apply the most appropriate CBT intervention method. 

While CBT may seem to be an ideal treatment for a wide range of disorders, it is not without its limitations and shortcomings. Dr. Dandan sheds light on these limitations; while CBT is short-term in its nature, ranging from five to twenty sessions, unlike other treatments such as psychodynamic, it requires a patient’s commitment and own initiative. CBT can only be successful if the patient actively takes part in the treatment and completes their homework assignments between sessions. The aim of the therapy is that the patient eventually becomes their own therapist and is equipped with daily life-coping skills, which require a great deal of persistence to achieve the desired effects.

Furthermore, Dr. Dandan explains that the therapy can be inadequate for certain patients. While CBT is a highly structured intervention and can be administered in several different formats, it remains cognitively demanding. The therapy utilizes techniques such as abstract thinking, problem-solving, and self-reflection, and individuals with intellectual and learning difficulties may face challenges in these areas, which can impede their ability to fully engage in the therapy and retain what they have learned. CBT suffers from several other flaws, such as its main focus on the present, ignoring important developmental impacts, and evoking discomfort in patients as it directly addresses and challenges their emotions. Despite this, Dr Dandan underscores the essence of CBT, highlighting its focus on an individual’s ability to change, which can be as powerful as medication in addressing disorders.

The discussion then progressed from the core components of the treatment to its actual implementation. Using CBT, therapists help individuals identify negative automatic thoughts (NATs). Patients are often encouraged to keep a thought record, Dr. Dandan explains, which allows them to examine their thoughts and feelings about a situation. In addition, through Guided Discovery, a tool often administered in CBT, patients can further understand their thought processes, emotional responses, and behavior patterns. These techniques can help in identifying cognitive distortions, such as All-or-Nothing thinking or Catastrophizing. 

NATs are just the tip of the iceberg when it comes to the real problem, Dr. Dandan reveals. As individuals, we hold underlying or core beliefs that provide a framework for navigating life that we develop in our early childhood. They represent deeply held, unshakeable ideas and are at the very center of your belief system. These core beliefs give rise to rules and assumptions, which in turn, lead to NATs. For example, a student may hold a core belief that they are “useless” to make sense of certain, traumatic childhood events. Later, the student may experience being unreasonably scolded in school, which reinforces their belief of being “useless”, and leads to thoughts such as “I can’t do anything correctly”. 

Dr Dandan then transitioned the discussion from the theoretical aspects of CBT to its practical application, focusing on case formulation. To formulate a case, the therapist must collaboratively construct an understanding of the patient’s problems, drawing on various inputs and perspectives. The first step usually involves a detailed, diagnostic assessment of the patient’s background, presenting problem, and baseline level on the severity of symptoms. During this stage, a therapist may administer The Patient Health Questionnaire (PHQ-9), a diagnostic instrument, to gather information. 

Based on the case formulation, the therapist develops a personalized treatment plan. Before beginning the treatment, it is essential that a therapeutic alliance has been established to foster motivation in the patient and instill confidence in the proposed treatment plan, Dr Dandan explains. Throughout treatment, sessions typically adhere to a structured format, usually starting with a review of the assigned homework. Dr. Dandan emphasizes that the treatment is both time-limited and goal-directed, therefore it is essential to ensure that patients are made aware of the end and duration of the treatment; failing to do so could result in challenges when concluding therapy.

Dr. Diab took the lead in the discussion by exemplifying the information discussed in real-life scenario cases, allowing the audience to offer their perspectives and approaches to each case. She began with the case of a girl named Sara, who finds herself always ending relationships when they start becoming serious due to her fear of commitment and loss of personal freedom and independence. In approaching this, we should identify Sara’s underlying thoughts and beliefs, and allow her to challenge and restructure these thoughts. Furthermore, we must teach her coping mechanisms when she is faced with these thoughts and feelings, as well as assign her homework to maintain her progress and practice new skills between sessions. Finally, we’ll reassess the consequences of her thoughts and behaviors, allowing Sara to examine how her thoughts influence her emotions and actions and develop the skills to regulate these emotions. Through these case examples, Dr. Diab reminds us of the complex nature of CBT, emphasizing that each individual’s case demands a detailed and personalized approach.