What is CBT?
CBT stands for Cognitive Behavioural Therapy
Cognitive refers to our thinking and beliefs, how our understandings of the world shape our responses to it including how we feel.
Behavioural refers to how we act and what we do, and how our behaviour is shaped by our past experiences of the responses or outcomes that arise because of certain actions.
Therapy that results from this understanding is a way of changing our feelings and our behaviour by addressing the relationship between thinking, feeling, and behaving (acting).
The fundamental premise of CBT is:
Our underlying beliefs and assumptions affect our thoughts, which then affect our feelings and our actions. To improve someone’s well-being, CBT seeks to address two specific areas of thought:
Thoughts and ways of thinking that contribute to emotional/mental distress.
Thoughts and ways of thinking that contribute to or reinforce undesired or unhealthy behaviour.
CBT is focused on addressing specific issues that are causing people problems.
It aims to identify the area of concern, and develop practical strategies and skills that can be used in day-to-day life. A central part of CBT strategy is the ability to identify and challenge the thoughts that shape the troubling emotion and/or behaviour.
Research has found that the most effective way of addressing unhelpful thought patterns is by reinforcing positive, flexible, healthy alternatives. The end goal of CBT, whether delivered by a therapist or a self-help program, is for the person to “become their own therapist” by using CBT techniques in their everyday life. Some of the strategies that can be part of CBT include learning to:
- Understand how assumptions, thoughts and beliefs cause distress
- Recognise and identify unhelpful, extreme, and distorted thinking
- Re-evaluate and change thoughts and beliefs that are causing problems
- Confront and address fears instead of avoiding them
- Calm the mind and body
- Develop confidence in a person’s own abilities and healthy self-esteem
- Use problem-solving skills to cope with difficult situations
- Change behaviour to help create more positive outcomes
- Gain more a realistic and insightful understanding of others’ behaviour
The gold standard of therapy
CBT has been used since the 1960s. It is considered the “gold standard” of therapy because it has been proven to be both effective for a wide variety of mental health concerns and a way to see significant changes in a short period of time. CBT has been proven helpful and effective for a wide range of issues including:
- Managing chronic pain
- Panic disorder
- Eating disorders
- Obsessive-compulsive disorder
- Post-traumatic stress disorder
- Anger management
- Low self-esteem
This basic overview of CBT does not cover every aspect of CBT or the full experience of doing CBT with a professional therapist. It does, however, introduce the fundamental principles which have shaped the design of the Thinkladder app to provide a simple self-awareness experience. The Thinkladder app draws on these aspects of CBT to enable users to discover and identify the unhelpful thoughts, assumptions and beliefs that are causing them problems, and to then challenge and change them with positive alternatives:
Users start with the feeling/behaviour that is causing them concern by choosing a general Theme, and selecting a Symptom that best describes what is wrong.
They then explore the potential unhelpful thoughts or beliefs that could be fuelling those symptoms, and identify which is most relevant to them.
To challenge and replace the unhelpful belief, users then select an empowering alternative belief (Insight) that they want to strengthen and reinforce.
CBT, and the Thinkladder app, are based on the idea that change is possible, even to long-standing ways of thinking and deeply held beliefs. In the next section, we talk about how change happens in our thinking and our brains.
Change and the Brain
Have you heard of the concept of neuroplasticity? This is the idea that our brains can and do change (like plastic can be moulded – it’s the same root word). Thoughts create pathways and connections in our brain – the great thing is, we can choose to create new thoughts and new patterns in our brains.
One way that is proven to help create change is repetition. This is why we encourage people to set Reminders so that they are focusing on their alternate belief every day until it replaces the unhelpful belief they wanted to change.
Change is possible! Although many scientists even 20 years ago believed that our brains developed through childhood and were then fixed through adulthood, since then, an enormous amount of research demonstrates that there is plasticity in the brain beyond childhood. This means that changes in the structure and activity of many parts of the brain occur, often in response to trauma or injury. These changes also happen over time because of repetition, habit, and practice. For example, taxi drivers have structural differences in parts of their brains associated with visuo-spatial skills, and people with anxiety disorders who undergo cognitive behavioural therapy (CBT) show changes in the way their brains process fear even after less than ten sessions.
Psychiatrist Jeffrey Schwartz (link to video), describes the changes that you can cause in your brain as ‘self-directed neuroplasticity’ – you can cause changes in your own brain. When you use the Thinkladder app, you are going to be doing self-directed neuroplasticity. We will focus on bringing healthy change to one small part of your life. You will be developing skills that people throughout the world have used to create change, and overcome depression and anxiety.
The two processes of neurogenesis (creating new neurons) and neuroplasticity (changes in structure and function of neurons) are the subject of intense investigation now because their mechanisms are not completely understood. What is clear is that changes in the brain do occur, and it is likely that when you learn something as an adult, the effects in the brain are not so different from when you learn something as a child. So, understanding how we learn and build memories and beliefs is crucial if we want to use that information to engage in self-directed neuroplasticity.
Think about some of the ways we learn intuitively or even automatically:
- Hearing/reading a new concept.
- Thinking about and concentrating on the concept
- Repetition, rote learning
- Watching others model a behaviour
- Imagining others or ourselves carrying out the behaviour
- Practising different states and behaviours in our own time
- Practising these new thoughts, states and behaviours in context
We know intuitively that learning things well takes concentration, practice, and perseverance. You might have heard that experts in any activity have 10,000 hours of practice behind them – this has been often misunderstood, and the original researchers have emphasised that the most important kind of practice is deliberate practice. Deliberate practice is not just repeating what you can already do, but involves challenging yourself to work beyond your current capabilities, and if there’s a strong enough structure to it, you can actually make a lot of progress in much less than 10,000 hours. You can see a good example in Josh Kaufman’s TEDx talk. What you pay attention to constantly in your conscious world has the potential to change your brain.
Similarly, when you’re busy focussing on a new thought/experience/behaviour, it means that you are doing LESS of the old routine. You are doing something better, healthier instead. You use it or lose it. Your brain is always being shaped: it’s an ever-changing landscape and you can be the gardener and even plant the seeds that grow into new ways of thinking and feeling.
Think about what potential you have to use deliberate practice to self-direct neuroplasticity in your favour. We can actually decide every day to make our thoughts and beliefs different and healthier, little by little. The Think Ladder app uses CBT to help you give yourself a healthier brain by using repetition and Reminders to activate your neuroplasticity.
How can I get the most out of the Think Ladder App?
Use the app correctly for the best results
Understand how the process works. Countless studies have proven CBT’s effectiveness, and the more that you believe that it can help you, the more effective it will be.
Use the app regularly, and use the notification feature to engage with your insight(s) every day until they become a part of you. To change a mindset takes repetition and time.
Be honest with yourself. Getting to the heart of your beliefs takes practice, but if you are honest about what you are really thinking and feeling you will be able to make changes. This is exciting!
Be patient – don’t expect instant results. Your thinking patterns have taken a long time to develop, and it will take time before you see changes. Don’t give up!.
Remember that there is no shame in getting help. If you are really struggling or in a crisis, talk to a medical professional like a counsellor or your GP.
Thinkladder App Content: Themes
The Thinkladder master list of themes was compiled from three primary sources:
- The DSM 5: The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published by the American Psychiatric Association is considered an international standard.
- The ICD-11: The World Health Organisation International Classification of Diseases (ICD-11) has been designed for global application and is also regarded as a standard measure implemented worldwide.
- ThinkLadder’s mental health professional network: Thinkladder’s collaborative process further provides a grounded and cross-checked source of themes based on the experience of mental health professionals.
The items on the DSM-5 and ICD-11 (Section 06: Mental, behavioural or neurodevelopmental disorders) diagnoses lists were aggregated and sorted for relevance. Neurocognitive disorders, some neurodevelopmental disorders, schizophrenia spectrum and other psychotic disorders were excluded. Most categories were aggregated as general themes (such as substance use disorders and addiction, and bipolar and related disorders). However, specific DSM-5 diagnoses which relate to external or stage of life events (primarily V codes) have been combined separately to themes relating to life-course and specific events such as illness or trauma. These have also been informed by the ICD-11 sections 23-24 (23: External causes of morbidity or mortality; 24: Factors influencing health status or contact with health services).
Thinkladder is designed to complement wellness routines. Studies show that apps are most useful when used in conjunction with other professional support. It is not designed to be a substitute for traditional therapy. The Thinkladder app does not provide any diagnosis, nor medical/clinical recommendations.
If you are experiencing a medical or mental health emergency, seek professional help immediately. Thinkladder is not designed to address crises and/or severe mental health circumstances, including self-harm, suicide or suicidal thoughts, abuse, or any medical/mental health emergencies. If you or someone you know is facing such a crisis, seek help from your local crisis line or medical/mental health professional immediately.
The Thinkladder app is designed for use by adults who can make informed decisions according to the Terms of Service. It is not designed to be used by children under 13. Youths aged 13-17 and those under guardianship should only use the app under supervision of a parent, guardian, or mental health professional.
1 Vanessa Skinner and Nick Wrycraft, CBT Fundamentals Theory and Cases, 2014, p. 7.
2 Skinner and Wrycraft; APA, ‘What Is Cognitive Behavioral Therapy?’ (American Psychological Association, 2017) https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral.
3 Skinner and Wrycraft; Michelle G. Craske, Cognitive-Behavioral Therapy, Theories of Psychotherapy Series, Second edition (Washington, DC: American Psychological Association, 2017).
4 APA, ‘What Is Cognitive Behavioral Therapy?’; Skinner and Wrycraft.
5 Skinner and Wrycraft, p. 32; Christine A. Padesky, ‘Schema Change Processes in Cognitive Therapy’, Clinical Psychology & Psychotherapy, 1.5 (1994), 267–78 https://doi.org/10.1002/cpp.5640010502; Angela Fang and others, ‘Mechanisms of Change in Cognitive Behavioral Therapy for Body Dysmorphic Disorder’, Cognitive Therapy and Research, 44.3 (2020), 596–610 https://doi.org/10.1007/s10608-020-10080-w; Eshkol Rafaeli, David P Bernstein, and Jeffrey E Young, Schema Therapy: Distinctive Features, 2011 https://ebookcentral.proquest.com/lib/sfu-ebooks/detail.action?docID=589566 [accessed 11 May 2021]; Diane McNally Forsyth and others, ‘Measuring Changes in Negative and Positive Thinking in Patients With Depression’, Perspectives in Psychiatric Care, 46.4 (2010), 257–65 https://doi.org/10.1111/j.1744-6163.2010.00253.x; Philippe R. Goldin and others, ‘Changes in Positive Self-Views Mediate the Effect of Cognitive-Behavioral Therapy for Social Anxiety Disorder’, Clinical Psychological Science, 1.3 (2013), 301–10 https://doi.org/10.1177/2167702613476867.
6 Skinner and Wrycraft; APA, ‘What Is Cognitive Behavioral Therapy?’
7 Craske; Daniel David, Ioana Cristea, and Stefan G. Hofmann, ‘Why Cognitive Behavioral Therapy Is the Current Gold Standard of Psychotherapy’, Frontiers in Psychiatry, 9 (2018) https://doi.org/10.3389/fpsyt.2018.00004; Stefan G. Hofmann and others, ‘The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-Analyses’, Cognitive Therapy and Research, 36.5 (2012), 427–40 https://doi.org/10.1007/s10608-012-9476-1.
8 Shayanti Chattopadhyay and others, ‘Cognitive Behavioral Therapy Lowers Elevated Functional Connectivity in Depressed Adolescents’, EBioMedicine, 17 (2017), 216–22 https://doi.org/10.1016/j.ebiom.2017.02.010; Robin B. Jarrett and Jeffrey R. Vittengl, ‘The Efficacy of Cognitive Behavioural Therapy for Depression’, in Treating Depression: MCT, CBT and Third Wave Therapies, ed. by Adrian Wells and Peter L. Fisher (Hoboken, NJ, USA: John Wiley & Sons, Inc., 2015), pp. 52–80 https://doi.org/10.1002/9781119114482.ch3.
9 Michelle G. Newman, Nur Hani Zainal, and Juergen Hoyer, ‘Cognitive‐Behavioral Therapy (CBT) for Generalized Anxiety Disorder (GAD)’, in Generalized Anxiety Disorder and Worrying, ed. by Alexander L. Gerlach and Andrew T. Gloster, 1st edn (Wiley, 2020), pp. 203–30 https://doi.org/10.1002/9781119189909.ch10.
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11 Maguire and others.
12 Månsson and others.
13 Malcolm Gladwell, Outliers: The Story of Success, 1. ed (New York, NY: Back Bay Books, 2008).
14 K Anders Ericsson, Ralf Th. Krampe, and Clemens Tesch-Römer, ‘The Role of Deliberate Practice in the Acquisition of Expert Performance’, Psychological Review, 100.3 (1993), 363–406.
15 Ericsson, Krampe, and Tesch-Römer.
16 Mayo Clinic, ‘Cognitive Behavioral Therapy’ (Mayo Foundation for Medical Education and Research, 2021) https://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/about/pac-20384610.
17 Diagnostic and Statistical Manual of Mental Disorders: DSM-5, ed. by APA, 5th ed (Washington, D.C: American Psychiatric Association, 2013).
18 Steeves Demazeux and Patrick Singy, The DSM-5 in Perspective: Philosophical Reflections on the Psychiatric Babel, 2015 http://site.ebrary.com/id/11029170 [accessed 29 October 2020]; Isabela S. Fortes and others, ‘A Cross-Sectional Study to Assess the Prevalence of DSM-5 Specific Learning Disorders in Representative School Samples from the Second to Sixth Grade in Brazil’, European Child & Adolescent Psychiatry, 25.2 (2016), 195–207 https://doi.org/10.1007/s00787-015-0708-2; Gen Li and others, ‘DSM-5 Posttraumatic Stress Symptom Dimensions and Health-Related Quality of Life among Chinese Earthquake Survivors’, European Journal of Psychotraumatology, 9.1 (2018), 1468710 https://doi.org/10.1080/20008198.2018.1468710; Malose Makhubela, ‘Latent Structure of the Post-Traumatic Stress Disorder (PTSD) Checklist for DSM-5 (PCL-5) in South African Mortuary Workers’, Journal of Psychology in Africa, 28.3 (2018), 206–11 https://doi.org/10.1080/14330237.2018.1475909.
19 WHO, ‘ICD-11 for Mortality and Morbidity Statistics’ (World Health Organization, 2020) https://icd.who.int/browse11/l-m/en.
20 Bo Bach and Fares Zine El Abiddine, ‘Empirical Structure of DSM-5 and ICD-11 Personality Disorder Traits in Arabic-Speaking Algerian Culture’, International Journal of Mental Health, 49.2 (2020), 186–200 https://doi.org/10.1080/00207411.2020.1732624; Cary S. Kogan and Sabrina Paterniti, ‘The True North Strong and Free? Opportunities for Improving Canadian Mental Health Care and Education by Adopting the WHO’s ICD-11 Classification’, The Canadian Journal of Psychiatry, 62.10 (2017), 690–96 https://doi.org/10.1177/0706743717717253; María Elena Medina-Mora and others, ‘ICD-11 Guidelines for Psychotic, Mood, Anxiety and Stress-Related Disorders in Mexico: Clinical Utility and Reliability’, International Journal of Clinical and Health Psychology, 19.1 (2019), 1–11 https://doi.org/10.1016/j.ijchp.2018.09.003; Hiroshi Mizushima, ‘Toward the Implementation of WHO 11th Revision of the International Classification of Diseases (ICD-11), ICF and ICHI’, Journal of the National Institute of Public Health, 67.5 (2018), 433–433 https://doi.org/10.20683/jniph.67.5_433; Tahilia J. Rebello and others, ‘Anxiety and Fear-Related Disorders in the ICD-11: Results from a Global Case-Controlled Field Study’, Archives of Medical Research, 50.8 (2019), 490–501 https://doi.org/10.1016/j.arcmed.2019.12.012; Geoffrey M. Reed, ‘Toward ICD-11: Improving the Clinical Utility of WHO’s International Classification of Mental Disorders.’, Professional Psychology: Research and Practice, 41.6 (2010), 457–64 https://doi.org/10.1037/a0021701.
21 Skinner and Wrycraft, p. 10.