Cognitive Behavior Therapy and Young Adults: An Interview with a CBT-trained Clinician

1. What is cognitive behavior therapy?

Cognitive behavior therapy (CBT) is an empirically validated form of therapy. This means it has been scientifically studied and found to be effective in addressing various mental illnesses that individuals experience. CBT focuses on the interaction of thoughts, feelings and behaviors and how these different components correspond to different mental illnesses (e.g., anxiety and mood disorders).

With CBT, a clinician works with an individual to understand how automatic, negative thoughts can contribute to emotional feelings as well as physical feelings and how the individual can engage in positive behaviors that help to manage these feelings. Behaviors can be adaptive or maladaptive, meaning behaviors can lead to healthier levels of functioning or can lead to poorer levels of functioning.

When I talk about CBT, I describe it as a form of coaching. The clinician is more like a coach who helps individuals practice thinking rationally, managing emotions effectively and developing healthy ways to cope with symptoms. CBT is a collaborative, two-person model so time is spent helping individuals feel comfortable talking about issues and helping them understand that these issues will be addressed collaboratively.

CBT is also a strength-based treatment so it does not focus on vulnerabilities or weaknesses but rather it offers the opportunity to develop strengths. The clinician will talk about how to use the capacities individuals already have to address the issues they are facing.

2. How does CBT differ from traditional forms of psychotherapy?

People often assume, rightly or not, that therapy is about digging into unconscious conflicts that are responsible for symptoms. This is a very old way of looking at the therapeutic relationship.

The word I use most to describe CBT is collaborative. It is two individuals in a room who are working on a common goal. As a result, CBT-trained clinicians are usually engaging, interactive and instructive. They do not just empathetically listen. They are there to help problem-solve and address troublesome symptoms that are getting in the way of an individual’s life.

CBT-trained clinicians focus on identifying practical strategies and adapting different behaviors to support recovery. They may talk about the dynamics behind symptoms, but this is not where they start. They typically start with the individual’s goals.

This is different from what clinicians typically do in traditional forms of psychotherapies. They usually do a lot less talking and teaching and only focus on the specific mental illness that is present.

3. What mental illnesses does CBT treat?

CBT is used for a variety of illnesses. At first, CBT focused mostly on mood disorders and anxiety. However, now it is used with lots of different mental illnesses, including schizophrenia, psychotic disorders, substance use disorders and personality disorders.

Once an individual learns about the CBT model, in terms of how thoughts, feelings and behaviors correspond with each other, it can be used to address many different, diagnosable mental illnesses as well as normal changes in feelings and behaviors.

4. What does a typical CBT session look like?

Oftentimes, CBT-trained clinicians will start the first session with an assessment of how well the individual is functioning and what specific issues he or she is there to address and how significant these issues are in his or her life.

There is a lot of initial talk about what the individual is experiencing and how his or her symptoms are impacting relationships, work, school, etc. Clinicians also take time to understand the onset of the issues the individual is experiencing and their clinical course. For example, they may ask questions like: When did you first start experiencing symptoms? How have they changed throughout your life? How have they impacted different areas of your life?

Most importantly, CBT-trained clinicians take time in the beginning to understand the individual’s treatment goals. It is important from the onset that they understand what the individual is looking for from treatment.

5. How can young adults get the most out of CBT?

In order to get the most out of treatment, coming up with goals is very important. Young adults should have a personal understanding of what they would like from treatment. Much more than other types of psychotherapy, CBT is collaborative, so the clinician is looking to understand what a young adult is looking to accomplish. This is going to direct the treatment itself. The clinician is there to help the young adult meet his or her goals.

There are homework assignments with CBT. These assignments can include working on challenging automatic, negative thoughts, monitoring symptoms and finding new ways to cope with symptoms. Homework is important to get a sense of the progress being made between sessions. Young adults need to be motivated to work outside of the treatment sessions.

I tell the young adults I work with that a lot of the work does not occur during the 50-minute sessions, but outside of the sessions. I openly encourage discussion via email and phone calls to get a sense of how my young adults are doing when we are not meeting.

I recommend young adults use a notebook to jot down thoughts, particularly automatic, negative thoughts. This helps to get a sense of the anxiety or discomfort these thoughts create and how these thoughts are triggered in different situations (at home, in school, with friends, etc.).

6. How can young adults locate CBT-trained clinicians?

Luckily, it is easier to locate appropriate clinicians now more than ever. Young adults can just go online and Google CBT and the state they live in to bring up clinicians. I had my practice advertised over the internet and most of my colleagues do this too.

Psychology Today (www.psychologytoday.com) provides a wonderful tool that allows people to type in a zip code and a list of clinicians and their specialties pop up. Young adults may also contact insurance clinicians. When I enrolled in BlueCross BlueShield, they asked me what my specialties were. Young adults can call their insurance clinician to ask for a list of CBT-trained clinicians that work within their insurance network.

7. What questions should young adults ask clinicians to ensure they are trained in CBT?

There are clinicians who advertise that they do CBT but they actually do more traditional psychotherapy. Here are some questions parents and young adults can ask to ensure what a clinician is advertising is CBT:

• Can you explain the difference between CBT and other types of psychotherapies? If the clinician is not able to give you a good sense of how CBT is different, they probably do not have a good understanding of CBT.
• What additional training have you received in CBT? I did a lot of training in CBT in my post-doctorate education so definitely ask what specialized training they have received.
• How do you organize your time within sessions? This will give a sense of how they spend time during sessions and if it sounds like CBT.
• How collaborative is your therapy? How much interaction occurs between you and your clients? CBT emphasizes collaboration and interaction much more than traditional psychotherapies so these are good questions to ask upfront. Some institutes offer credentials for CBT but it is not common. The Beck Institute for Cognitive Behavior Therapy (www.beckinstitute.org) is a great resource for credentialing.

8. Are there any issues you feel are unique to the young adult population?

There are three top issues I often see in young adults:

• Anxiety and mood disorders. There is a lot of anxiety that comes with this stage of life. Self-consciousness and insecurity create intense anxiety symptoms, including panic attacks, obsessionality and compulsivity, in young adults. I also often see mood fluctuations. This often looks like irritability, isolation and withdrawal in young adults.
• Sleep problems. Sleep difficulty is one of the most common presenting symptoms for young adults. Their minds are racing at night, which prevents them from falling asleep. I work with them to shut down these thoughts or challenge those thoughts so they can sleep.
• Bullying. This is a huge issue and cyber bullying is an increasingly challenging issue. Social media websites are used to pick on young adults and find ways to reach them outside of school. This means young adults have no safe haven from bullying. They cannot be free from negative feedback. Bullying is an issue that needs to be addressed as soon as a young adult starts to feel isolated.

9. What books, websites or other resources do you recommend to young adults who want to learn more about CBT?

I recommend the following resources:

• The Beck Institute for Cognitive Behavior Therapy at www.beckinstitute.org
• The National Association of Cognitive-Behavioral Therapists at www.nacbt.org
• The Center for Anxiety and Related Disorders at www.bu.edu/card
• Psychology Today at www.psychologytoday.com

I always enjoy books by David Barlow. Another author, David Burns, does a lot of contemporary work with CBT and has several self-help books that include specific strategies people can use to address negative thoughts.

10. What strategies from CBT can young adults use in their everyday lives to address negative thoughts?

Strategies I recommend to young adults include:

• Keeping a thought notebook. It is always helpful to log thought processes throughout the day and week. It helps to make thoughts more concrete. It is also helpful to use a friend or family member to provide reality testing for the thoughts. They can ask questions about negative thoughts, look for evidence to support the negative thoughts and challenge the negative thoughts.
• Thought-stopping techniques. A lot of people do not realize that they can control their thoughts. There are techniques that can be used to do this. When negative thoughts occur, try saying “stop” out loud or internally or picture a stop sign or a police officer holding up his or her hand. Sometimes individuals wear a rubber band around their wrists and snap it when they have a negative thought. This helps to bring more awareness to these thoughts, which then allows them to challenge their thoughts. These techniques help reign in negative thoughts. CBT is designed to help people develop these techniques.
• Relaxation techniques. These techniques include deep breathing, progressive muscle relaxation, visual imaging and meditation. These approaches can help young adults deal with emotions that can come from negative thoughts.

11. Is there anything else you would like to add about CBT?

One thing I love about CBT is it is a very hopeful and optimistic, strength-based treatment. CBT-trained clinicians are using resources young adults already have to address the symptoms that are interfering with their functioning. Together, young adults and their clinicians can make a change. The clinician is a supportive person that young adults can be genuine with and trust. CBT is all about working together on common goals.

by Jonathan E. Goldberg, Ph.D., licensed psychologist, clinical instructor of psychiatry, Harvard Medical School.