There are four important stages in CBT treatment. You and your therapist work together at each stage:
1 Assessment stage |
2 Cognitive stage |
3 Behaviour stage |
4 Learning stage |
In the Assessment stage, you and your therapist get to know each other. Your therapist usually forms a treatment plan, and often has some idea about how long your treatment might take.
In the Cognitive stage, you and your therapist work together to understand your thoughts. You might spend some time discussing past events that have made you think the way you do.
In the Behaviour stage, you and your therapist work together to find new patterns of thinking. You apply your new patterns of thinking to new behaviours.
In the Learning stage, you and your therapist work together to make sure that the changes are permanent. You learn how to use the principles of CBT for yourself in future, so that you can cope with future events without needing any more therapy.
The four stages are not always separate. They can get a bit mixed up. This is because CBT is not a rigid system of therapy with fixed rules. But successful CBT always has all four stages.
The following sections describe each stage in more detail.
When you have your first session with your CBT therapist, expect to spend some time getting to know and understand each other. This is Stage 1.
Your therapist will probably explain how CBT works. It should be something like the explanation on this web site. Different therapists explain things in different ways, though, so do not expect it to be exactly the same.
Your therapist will probably ask you questions about your condition. This is so that your therapist can make an assessment of the treatment that you will need. Be specific about the things that affect you most.
Your therapist might ask you what you hope to gain from therapy. It is helpful if you can explain how you would really like your life to be after successful therapy.
By the end of the first session, you should have a strong feeling that the therapist is on your side. You should feel positive about working together with your therapist to make your life better. In CBT jargon, working together like this is called a therapeutic alliance. It is an important part of CBT.
If you do not have this strong feeling, consider whether this therapist is right for you. Be sure to mention this at the beginning of your second session. Your CBT therapy might not be very successful if you do not form an alliance early on.
By the end of the first one or two sessions, your therapist usually has a treatment plan in mind. The plan might enable your therapist to estimate how many sessions you will need for treatment. There is no fixed pattern in CBT treatment, though. The plan might change because you improve unexpededly quickly. Or it might change because some new issue emerges and you need to spend extra time to address it.
In the cognitive part of CBT, you learn to understand and control your own thought processes. This is Stage 2.
Sometimes the way you think now is the result of how you learned to think in the past. So in this stage of CBT, your therapist might spend some time with you understanding events in your past. CBT does not focus on the past. The only reason to understand your past is when it helps you to understand your present thought processes. In CBT jargon, thought processes in your past that influence your present thinking are sometimes called schemas.
Sometimes you think about things in a certain way because it seems the only reasonable way. Your therapist might explore whether the ways that you think about things really are reasonable. For example, you might discuss the evidence together. Or you might try some experiments to find the most reasonable way to think about things.
Between therapy sessions, you usually perform activities that are related to this work. For example, you might keep records of your thoughts each day.
Stage 2 is often not very clear cut. You cannot easily tell when it begins and ends. Instead, you spend some time understanding your thought processes in each of your therapy sessions.
By the time you have had a few sessions of CBT, you should be starting to understand your own thought processes. You should be starting to see how your thought processes are related to the symptoms that you are trying to address. And you should be starting to find ways to take control of your thoughts, so that you can take control of your symptoms.
This work continues throughout your CBT treatment.
In the behavioural part of CBT, you learn to understand how your thoughts and your behaviour influence each other. This is Stage 3.
Sometimes the things you do influence your thoughts. Sometimes the things you think influence your behaviour. In this stage of therapy you establish patterns of thought and behaviour that help you to manage your symptoms.
Between therapy sessions, you usually perform activities that are related to these new patterns. For example, you might practise interacting with people in new ways. Or you might practise handling specific situations, so that you gain control of what happens.
Stage 3 is often not very clear cut. You cannot easily tell when it begins and ends. You might spend some time working with behaviours in each of your therapy sessions.
By the time you are approaching the end of your CBT treatment, you should be applying what you have learned in real life situations between tharapy sessions.
Towards the end of your CBT treatment, you usually become prepared to stop therapy and deal with your symptoms by yourself. This is Stage 4.
In a sense your therapy does not stop. Your sessions with the therapist stop, but you continue the treatment on your own. You become your own therapist.
One of the important differences between CBT and other treatments is that in CBT you learn to treat yourself. So if you have a long-term condition, the benefits of CBT continue in the long term.
If your condition is completely addressed by CBT therapy, you can still use CBT techniques by yourself in the future. You can use them to deal with relapses, or with completely different issues that arise in your life.
Like the other stages of CBT, Stage 4 might not be very clear cut. You start to work with your own symptoms in the early sessions of your CBT treatment. You simply continue doing this after your treatment has ended.
So as you approach the end of your treatment, you should have a firm inner confidence that you can practise the things you have learned by yourself. CBT should allow you to be independent and to manage your condition without further intervention by a therapist.
The four stages of CBT should always produce beneficial results. This fits in with many research findings. CBT has been tested in a similar way to other therapies like drug therapy. These tests generally show that CBT is effective.
There have also been reports that CBT does not work so well in some cases. It is not yet clear why this is. For example, in one reseach study CBT was used to treat depression. Some patients got better and some did not. No one completely understands the reasons for this. One possibility is that some CBT therapists leave out one or more of the four stages.
For example, in that research study there were five therapists. Three of them seemed to get good results, but two of them did not. It has been suggested that the two therapists whose results were poor did not spend time getting to know their patients and allowing their patients to get to know them. They left out Stage 1.
A patient once told me that her previous therapist had not discussed any thought processes, but had gone straight from the assessment to behavioural activities. The therapy did not work very well, and the patient was referred to me. That therapist seems to have left out Stage 2.
When a stage of the CBT process is left out, it does not mean that the therapy is completely useless. A limited form of therapy can be useful for some people. But CBT probably works best when it is used in a complete way, as it was originally designed.
Good CBT treatment starts with a strong feeling of alliance between you and your therapist. From there you move on to understand your thought processes. Then you apply this understanding to real life behaviours and situations. When therapy ends, you are able to use the things you have learned independently in your daily life. You should be able to identify all these four stages in your therapy, even if they are a bit mixed up.
If you feel that your CBT therapist has left out one of the stages, then you should discuss this with your therapist. It might be that your therapy has taken an unusual course for some reason. CBT is not a rigid process. It does not fit exactly the same pattern for every patient.
Even if you are not able to address one of the stages with your particular therapist, your therapy might still be useful. But you might also want to consider finding a new therapist.
In addition to the four stages, good CBT treatment should take place in an appropriate professional context. Use the links on this site to find the professonal organizations for CBT therapists in your country. These organizations publish guidelines and maintain standards.
© 2004, 2008 Louise Ritson. All rights reserved.