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What Makes a Cognitive Behavioural Therapist Use the Cost-benefit Analysis in CBT

In itself, a cost-benefit analysis is not a Cognitive Behavioural Therapy (CBT) technique but used by CBT therapists to help clients examine and manage thinking and emotions in a natural process of problem-solving.  We all reflect on the pros and cons of our options when doing something new, e.g. going to a first date (or back for the second), accepting a job offer, renting or buying, smoking, losing weight, going to a social event, moving to London, finding a CBT therapist.  The cost-benefit analysis helps CBT therapists identify sticking points.

The Advantages for CBT Therapist When Using a Cost-benefit Analysis in CBT

Excessive dwelling or worrying stops us from making decisions and can lead to feeling overwhelmed procrastination or avoidance.  First of all, the analysis helps us to objectively define the problem, sometimes the hardest task of all; requiring some backtracking if we have been worrying for a while.  A worry process can lead us down a long track of unsettling predictive cognitions (our “What if…” thoughts of hypothetical thinking). Asking ourselves actually “what am I worried about?” brings us back to the source concern.  Importantly, for problem-solving asking, “what are all my options?” and considering their consequences can be illuminating.  When we are anxious or depressed, emotions can skew our thinking process – how we perceive events, store and recall memories.  A cost-benefit analysis can bring order to our thinking, by writing down on the page stops churning and jumping thoughts from one worry to another.  This brings a helpful element of objectivity that can interrupt overgeneralising adverse events and minimising positive experiences, a common thinking style in depression. On the flip side, from a CBT perspective, with anxiety we tend to have an orientation to identifying negative predictions and an overestimation of a threat when considering consequences, i.e. when we are feeling anxious, we generate anxious thoughts, anxious thoughts make us feel anxious.  The cost-benefit analysis prompts us to look at other outcomes promoting an element of objectivity, by ‘getting it out of our heads’.

What underlying process is the CBT therapist addressing with a cost-benefit analysis in CBT?

The CBT therapist knows that our difficulties are rooted in our earlier experiences, not just early.  From childhood and in adulthood, we all develop natural and healthy strategies for coping with what life has to throw at us; these are called our “rules for living”.  Rules, in our CBT definitions, are behaviours that are put into action when our assumptions are activated, but sometimes our assumptions can become inflexible and unhelpful.  If I have an assumption that:

  • “I always need to be prepared”, then this cognition may lead to developing an extreme rule for excessive planning.
  • “I must find the perfect solution” then behaviourally I may tend towards the unobtainable perfectionistic traits.
  • “I won’t cope if I am not prepared” then with this conditional cognition I might develop intolerance of uncertainty, leading to an infinite search for certainty (an internal behaviour of worrying).

We can also get stuck with ineffective problem-solving when we allow our emotions to be our guiding light to what we do, our behaviours.  If I make my decision by emotional reasoning, acting on how we feel, sometimes very little will get done.  For example, low mood, fear, guilt and shame can be normal reactions to a given situation, but if these are to be avoided (at all costs), then I may avoid thinking how to fix it, avoiding problem-solving.  A very nice gentleman that presented with depression had many failed relationships around him.  Becoming isolated made him sad because he valued and longed to be with people.  When small issues happened (e.g. cancelling at the last minute, not paying a loan back, etc.) he never addressed them because it felt unconformable. The ‘minor’ events or considerations continued with some getting bigger (because we assumed that others did not know he was offended) but he felt resentful and would withdraw.  To cope with his relationship becoming distant, he moved to London, but this avoidance and withdrawal led to family, friends, and romantic relationships eventually fizzling out.  Taking the problem with him and starting work in London prevented him from developing new relationships in a busy new city.  In this example, balancing the consequences of talking to people about how he feels in the short against the long-term can help with emotional reasoning.  Avoidance might provide some short-term relief, but in the far term, we may risk losing what we value most.

A cost-benefit analysis can help a CBT therapist to unblock many types of unhelpful behaviours such as rituals, impulsive behaviours, and procrastination.  Identifying the cognitive and behavioural factors that maintain difficulties sometimes lead naturally to what we need to do next.

Completing a Cost-benefit Analysis

The cost-benefit analysis can be as simple as drawing a line down the middle of the page writing pros on one side and cons on the other, then brainstorming everything that comes to mind after that.

We need to consider the advantages/benefits against the disadvantages, but this form helps us to break elements down further into a time frame (short and long-term), and also about ourselves and other people.

Frequently cognitive blips or excessive rule lead to ineffective problem-solving by a focus on irrelevance. What I also like about this form is that it restricts us to six points, for each domain.  If I’m looking for the perfect solution, I will be locked in, analysing all the infinite options that are not the drivers for making a conclusive decision.

There is no right or wrong decision because decisions are driven and based on what is important to us at any given time.  Our decisions are contextual, in that they are formed on our own experiences.  Usually steered by our beliefs about how we see ourselves, others, the world and the future. However, sometimes it is useful to do some ‘research’ beforehand.

How to Use a Cost-benefit Analysis

When we decide to do something, we consider many options, sometimes by discussing with friends, sometimes researching the internet, so on and so forth. Eventually, we muse over the options, juggle it all up, and we do what feels right.  It is often useful to consider what information we need to assemble before we start to chew over our options.

Any research needs to be limited by planning a start time and end time. Equally, as you sit down to complete, plan a dedicated stop signal – duration, emotion, time, event.  If we cannot decide within the time, we should think about who we can consult for advice with this particular problem. This could be a family friend, work colleague or CBT therapist.

Be careful of your thinking styles, e.g. if I know I have perfectionistic tendencies then I need to be aware of what are realistic standards.  Likewise, for perfectionists, it will be important to plan what is “good enough’ within a reasonable amount of time.  We need to remember for the CBT therapist it is not about getting this right but getting it written; just do it. Resist returning to the analysis of the analysis.

What the CBT Therapist Finds

As a CBT therapist reviewing a completed cost-benefit analysis draws out the themes and directs our cognitive behavioural therapy path.  Often, pros and cons are weighted in opposite corners. Usually, people find a direction that is ‘obvious’, but it is always helpful to investigate how did the cost-benefit analysis unblock, and what needs doing to address this – by preventing the need for an intervention gives CBT its evidence base with lasting change.

Equally, if it is not leading to a solution, this can be revealing.  Usually blocking cognition and behaviours are connected with the endless searching for the perfect solution or needing to know what I don’t know.  CBT is not a cluster of techniques, but a line of enquiry based on a coherent theoretical conceptualisation and principle that we know are effective.  You cannot have behavioural change without cognitive change, and you cannot have cognitive change without behavioural change.  To this end, for a CBT therapist, the cost-benefit analysis is not a treatment technique, but a means to an end. It can be one of the many stepping stones to overcome an anxiety disorder or a depressive episode.

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