Cognitive Behavioral Therapy: An Overview
John Freedy – Family Medicine
Linda Austin – Psychiatry
Dr. Linda Austin:
I’m Dr. Linda Austin. I’m talking,
today, with Dr. John Freedy, Assistant Professor of Family Medicine here at
MUSC. Dr. Freedy, you mentioned in
another podcast that cognitive behavioral therapy is often used in the
treatment of post-traumatic stress disorder.
Can you describe, a little bit, in lay terms, what cognitive behavioral
therapy is? What are the principles and how do you go about using it in PTSD?
Dr. John Freedy:
Cognitive behavioral therapy, actually there are several variants of
it. Really, let’s talk about just the central
principles. So, it’s dividing human
experience into three areas: what you
think, what you feel, and then your actions, what you do. So, we would say people who are anxious have
some difficulty with their thinking process.
It’s somehow unrealistic. The
fact that they’re thinking is unrealistic may serve to maintain or even create
and worsen their anxiety. And if they’re
anxious, they may avoid certain things that could be good learning experiences
to teach them that maybe the way I’m thinking about this particular
circumstance or myself isn’t correct.
You sort of stay stuck with some understandable ideas, but some false
ideas, and ideas that aren’t particularly helpful to you in getting along in
your daily life.
Dr. Linda Austin: So, in other words, if you’re
frightened of something, like going into a swimming pool or going into a big
store, rather than experience that, you might avoid it, and so you never learn
a more practical or useful or even reality-bound way of thinking about it?
Dr. John Freedy:
That’s exactly right. Or, another
variation on that is you might try to go into the store and get about 30 or 60
seconds into the experience, or even two or three minutes into the experience,
and become overwhelmed and get out of that situation. And then that would reinforce the ideas, see,
I can’t do it; it is overwhelming, it is impossible. I just am not competent; I can’t overcome
Dr. Linda Austin:
So, when you think about someone with post-traumatic stress disorder,
then, what are the thoughts and feelings that you’re trying to modify?
Dr. John Freedy:
Well, what we think happens to people is they go through this extremely
intense experience where they’re either severely injured or they perceive that
they could be severely injured or killed, or somebody is killed, and something
akin to Pavlov’s Dog happens, what we call classical conditioning. Or, we could also call that a fight-or-flight
response. The person is extremely
frightened and so their body releases certain chemicals; adrenaline is a common
name for it. But, your heart starts to
pound. Your palms get sweaty. Your mouth gets dry. And you feel
extremely fearful of the circumstance.
Then later on what happens is, if you are somehow
reminded of that circumstance, by a person or people or by a place, or other
circumstance, the original fear response comes back. And so what happens is the person often,
unknowing to themselves, starts to restrict their life. They won’t go out of the house, or they’ll
limit the times they’ll go out of the house or the places they’ll go out of the
house or the circumstances required.
They have to have somebody with them, or it has to be daylight. And what they’re really trying to do is to
behaviorally avoid setting off this fight-or-flight response that was
originally experienced during the trauma itself. And so they get this idea that I can’t;
the world is no longer safe. I am no
longer able to do x, y, or z, which, as a matter of fact, may or may not be
true. It oftentimes is not true. And that’s what the psychotherapy becomes
about, relearning some things.
Dr. Linda Austin:
So what are some strategies then that you teach in cognitive behavioral
therapy to help that person?
Dr. John Freedy:
You’ll notice that it’s cognitive behavioral therapy. So the biggest emphasis is on thinking. Another way of saying that is the biggest
emphasis is on knowledge or understanding.
So, the first two to three sessions, there’s a lot of talking about what
symptoms you’re having and why you’re having those symptoms. So it’s back to a classically conditioned
fight-or-flight fear response, and let’s look at all the ways that your
behavior is a form of avoidance now to keep that fear dampened down. And we tell the person, that is completely
logical; it’s totally understandable, at a time where it’s been one, two,
three months, six months, a year or more since this happened. And people in the person’s life don’t
understand and may even be very frustrated with the individual for having these
symptoms and not being able to do certain things. So, we get away from shaming and we point
The second thing we do
is we build up skills for the individual.
Ultimately, we’re going to want to expose them to these things that
they’re avoiding. But we don’t want to
do that and have the person unarmed. So,
we’re going to teach different coping skills:
deep breathing skills, progressive muscle relaxation. Another one we talk about is cognitive
restructuring. Instead of having
catastrophic thinking, what I like to call lions and tigers and bears, oh my,
we talk about what’s a more realistic way to think about a circumstance,
including, you can think about if a person is having a panic attack and admits
to being exposed to something that’s fear-inducing, one of the things I talk
about is your body is wired that you physically cannot have
a panic attack for more
than 15 to 30 minutes.
If you walk into a
situation and have a panic attack, it will be over in a matter of minutes. And most people are very surprised to hear
that. They don’t quite trust it at
first. But at some point, they
experience it going on for 5 to 15 minutes, and by nothing but staying there,
it goes away. And it’s very powerful; so
this isn’t going to kill me. I’m not
going to be overwhelmed. It is a
different circumstance. It’s
uncomfortable but I can get through it somehow.
Dr. Linda Austin: So, it sounds, then, as if it’s a therapy
that is very much geared toward symptoms, symptom relief, problems in the here
and now, as opposed to going back to childhood relationships and so forth, but
to offer very practical strategies for feeling better.
Dr. John Freedy: It’s very practical. It’s very problem solving. And it’s very much putting the control into
the person’s hands once they learn, as I said, number one, an understanding of
the condition, number two, a set of coping techniques, cognitively and
otherwise. Number three is being exposed
to the people, places and things you’re avoiding because it sets of the
anxiety. The therapist is not going to
force you to expose yourself to those things until you are ready. You are given the control of going into that
situation. And if you try an assignment,
and there are homework assignments to try at home, and you fail at it, that
becomes material for therapy where you talk about what happened, what went
wrong, and what could we do differently.
So, instead of it being
a sort of failure, it’s a learning experience that is very realistic for the
person in terms of motivating them to go back and try again, or maybe try
another situation that is anxiety-provoking, but not quite as anxiety-provoking
as the one that they failed at. And they
can come back to the so-called failure experience at some later point in time
when they feel more confident in their own abilities.
Dr. Linda Austin: Is talking about the trauma itself an
important part of that therapy?
Dr. John Freedy: It can be.
And, remember, we said cognitive behavioral therapy is really a family. It’s several types of therapy. So, for example, Patty Resick in St. Louis has what’s
called cognitive processing therapy. And
this was particularly developed for sexual assault victims. And she has a lot of talking and a lot of
journaling where the person is to write about the experience. And the point is to look at certain beliefs
that were shattered that have to do with trust, intimacy, control. There’s a theory of certain beliefs being
damaged, and damage to those belief systems is what the problem is.
So, there are
variants. And it depends on what the
trauma is. It depends on the training of
the therapist as to whether you’re going to get more into the, should we say,
the philosophical or existential meaning of what this has done to your life and
what you can do to work that through so you feel better about your
circumstances and your future.
Dr. Linda Austin: And, how important is the relationship with
the therapist for this process? Is that
key, in your view?
Dr. John Freedy: I think it’s absolutely essential. I think a lot of the traumas that are the
most damaging are interpersonal traumas.
They’re violations of trust. So,
being in a trusting relationship with a therapist, with a doctor, a healer is
very important, as is being in a trusting relationship with other people in
your life, friends, intimate partners, ministerial individuals, this sort of
thing. I think it’s essential you don’t
heal outside of that context.
Dr. Linda Austin: What would you suggest for someone who doesn’t
feel comfortable with their therapist?
Dr. John Freedy: I think the most important thing is to be
honest with yourself, as with any other relationship. And, if things aren’t working out, if it is a
possibility to talk with the therapist about your comfort level and whether
things can be worked out, if the therapist is well trained and experienced,
they will be able to talk with you about that.
And therapists are trained ethically, if there is a block for whatever
reason, if it can’t reasonably be worked out, to try to help you with a
referral to somebody else where you could try to form a better bond that would
be more helpful to you.
Dr. Linda Austin: I would think the challenge would be trying
to understand, is this a reliving of the difficulties with trust so that the
person would have trouble trusting any therapist, or is there really something
going on that the fit between the patient and that therapist just isn’t good,
or the therapist just isn’t the right therapist for that patient?
Dr. John Freedy: And I think that’s exactly the sort of
material that the therapist and the patient need to go over if there are those
difficulties to come to an honest conclusion of what’s best for that particular
Dr. Linda Austin: Dr. Freedy, thank you so much for talking
Dr. John Freedy: Thank you.
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