Therapy can be faster paced, focused on symptom relief and employing a more active collaboration aimed at unearthing negative or unhelpful ways of thinking and at building and strengthening “new muscles” in the mind. For example, by actively monitoring feelings and bodily reactions, one can become aware of underlying images and thoughts that are often unrealistic and catastrophic, and that may cause anxiety and depression. It can indeed be a detriment to the patient to talk about fears for years on end without getting off the couch and gradually facing them and developing a more realistic assessment of their situation.
Cognitive Behavior Therapy is a form of therapy that is based on active participation between the therapist and the patient. It is based on Socratic dialogue, which is a dyadic form of exploration in which the therapist and patient explore thoughts and feelings, testing the truthfulness and validity of those thoughts. The idea is that thoughts influence feelings and feelings influence thoughts. If one’s thoughts are negative, then one can suffer a downward spiral of increasingly more negative thoughts. In this type of work, therapist and patient often uncover distortions in thinking that need to be transformed into more truthful and realistic concepts. For instance, some people tend to catastrophize, seeing the world in black and white categories or minimizing their accomplishments and agency and maximizing their weak points and the accomplishments of others. The goal is to reassess objectively; as a consequence, feelings may also change. If there is some truth to a patient’s negative assessment and there are some real lacks and limitations that are constraining his potential, the therapist guides him to troubleshoot and learn new skills so that he can realistically catch up. In this type of work, there is no free association; the therapist interrupts if necessary and helps the session maintain its focus and the agenda for the day, which is mutually established at the start. The goal is to acquire skills and tools to become more aware of the processing of one’s mind, spotting downward mood changes, distortions, and risky behaviors, as well as challenging and modifying negativistic and anxious thoughts. One learns to interact with the mind like an accomplished defense lawyer; if the mind spews negative judgment or unrealistic self-representations, one develops an internal argument that refutes that perspective and proposes a realistic assessment of oneself and the situation. If the mind is prey to unhelpful desires and addiction, generating arguments that rationalize risky behavior, the more observant part of the mind, which CBT helps develop, recognizes and responds with new tools and skills. Over time, this person becomes more integrated and strong, accumulating successes and stability in life which makes “falling off the wagon” less likely. Even when that happens, the person has the tools to pick himself up again and address the issue constructively.
Sessions are participatory and intense, and homework is often assigned. Avoidance is addressed from the start, and a patient is helped to troubleshoot difficulties with procrastinating, maintaining abstinence from problematic behaviors and substances, curbing avoidant behaviors, and accomplishing assignments. Behavioral activation is an important part of the work; for instance, if a patient suffers from anxiety and avoids uncomfortable situations, the therapist helps him to explore and change his thoughts—first, by challenging his unhelpful thoughts, and then by reassessing the often faulty perception; but most importantly, she helps the patient devise a list of possible anxiety-provoking situations to explore in reality, so that little by little, the patient can come out of his protective shell and be engaged, conquer his fears, and build confidence in his abilities and skills so that he can tolerate increasingly more difficult situations. CBT is useful for depression and addiction and is the treatment of choice for ADHD, Phobia, Anxiety, and Obsessive-Compulsive Disorder.