Cognitive behavioural therapy (CBT) is considered the gold standard for treating depression and anxiety. The central principle of CBT is that the way we think powerfully affects our feelings and behaviours. CBT helps people recognize and challenge their negative or anxious thoughts in order to help them experience a sense of joy in life.
Dr. Khush Amaria is a Senior Clinical Director at CBT Associates, a leading Toronto-based psychology practice, who provides CBT treatment for children, adolescents, and adults with anxiety disorders, depression, and other health-related problems. She completed a BSc. at the University of Toronto, a PhD in Clinical Psychology at the University of Waterloo, and a Post-Doctoral Fellowship in Clinical-Health Psychology at SickKids Hospital. Dr. Amaria has been practicing as a clinical psychologist for nine years, and I was fortunate to have a conversation with her to learn more about the basics of CBT.
Can you explain to our lay readers what CBT is and how it works?
CBT is an umbrella term because it includes multiple methods. The key piece is that it involves a structured goal-oriented approach that is focused on how our thoughts impact our behaviours and our emotion. It focuses on present day challenges, thoughts and behaviours, and it does not tend to focus on your past experiences. CBT is time limited; the goal is to not keep you in therapy forever.
What you’re doing in the process is learning new skills to change your approach on how to manage problems and stressors. The individual isn’t just told what to do; they are guided by a therapist at a comfortable pace so that they can learn these new skills and make those changes outside of session time. With CBT, there is an expectation to do “between session” work, and these can be written exercises, behavioural experiments, or activities.
How effective is CBT in treating anxiety and depression relative to medications?
Of all the different approaches to therapy, CBT has been one of the most well studied. Academic institutions and hospitals have been trying to understand what changes take place in the individual if they’re using a structured CBT approach. Medications and CBT are often compared side by side, but there’s no rule, for the most part, that says you can't use both if that's necessary. We have what we call “pathways” to understand when either CBT or medication would be the first line of treatment. But for the most part, CBT is one of the first lines of treatment with the exception of specific concerns such as a psychotic disorder, with schizophrenia being an example. Of course, CBT on its own would not cure a severe mental health condition, but it can be used as an adjunct so that the individual can learn ways to reduce the risk of it coming back.
The key difference with medications is that they can work faster. But we also understand that, when they are removed, some of the previous challenges can re-emerge. By contrast, when you provide CBT, not only are the outcomes better at the end of treatment, but they can continue to improve even after treatment.
What are the most common thinking errors among people with general anxiety?
One of the most common ones we see are jumping to conclusions. It's this belief that you know the future. Of course, if you think you know the future and you're worrying and anxious, it's not because you're thinking that good things are going to happen, it’s because you’re thinking that bad things are going to happen.
Another common error is catastrophizing. That’s when you take something, and maybe that something is not going the way you want it to go, and you blow it up way bigger than it needs to be. Another common one is all-or-nothing thinking. What you're doing is you're seeing the world as black or white, and there are no shades of grey. When we think like this, there is often a sense of doom, especially if we have high expectations of ourselves.
Are there any CBT methods that you have found to be the most effective for treating general anxiety?
The first thing we do is get people to understand what their beliefs are about worry. People have beliefs that their worry can do good things for them, or that it will protect them from bad things happening. But, they may also be worried that their nervous thoughts are dangerous and that they can cause physical harm to them, or that they are going to make them go crazy.
When they understand their beliefs about worry, we get them to shift those beliefs. We can do that in a couple of ways. We get people to challenge their beliefs by getting them to find evidence that the belief is not true. We also get them to do experiments; for instance, we can see if they are able to purposely postpone their worry by getting them to schedule a “worry time.”
We have also found that many people who have anxiety are uncomfortable with uncertainty. They want to know what’s next, and maybe that feels safe and comforting, but it comes with a cost of worrying quite a bit. We encourage people, typically through experiments, to increase their tolerance of uncertainty. For example, we could have someone go to their usual restaurant, but instead of ordering the dish that they always get, we would encourage them to order something else off the menu.
What are the most rewarding experiences you have while doing your job?
I think it’s being able to teach somebody and give them an understanding of what they’re going through. When I'm able to do a systematic or diagnostic assessment with someone, they often feel less alone, and I can help them build hope really quickly. Whatever they’re feeling, experiencing, or suffering from has a possible solution or strategy. Sometimes we get to see immediate effects even if they’re minor.
For example, for generalized anxiety, we might teach relaxation techniques early on. We know that people with generalized anxiety tend to have fewer relaxed periods during their day. We can have them start with taking a long bath, doing yoga, or walking the dog. With these techniques, we often see an immediate effect.
What advice would you give to someone who is thinking about becoming a cognitive behavioural therapist?
This is quite a rewarding field to be part of and I think it's only going to grow. I think that if you are planning to be a therapist, it’s important to know that CBT is not a panacea. It’s not going to treat and fix everything, but we know that it’s the most well studied and is generally successful. If you want to make a difference, that's the treatment approach you're going to use.
Another important part is that you need to believe in the CBT model. I’m not saying that you should do therapy on yourself, but you must buy into this idea that a lot of our suffering comes from our interpretations and perceptions of the world, and this is something that we can change and have more control over through CBT.
Edited by Natasha Cheong & Kate Rzadki
Featured in Issue 3: Anxiety