How Cognitive Behavioral Therapy Can Help You
As a psychotherapist and a longtime patient of psychotherapy, I have had the good fortune of receiving both training and treatment in numerous schools of cutting edge psychotherapies including Cognitive Behavioral, Gestalt and Psychodynamic therapies. These experiences have helped me refine my sense of which therapies are most effective and have led me to incorporate these approaches into my work with my clients. Although I am first and foremost a Gestalt therapist (see my next article)- integrating Cognitive Behavioral Therapy (CBT) has been extremely helpful for many of my clients.
What is Cognitive Behavioral Therapy? Developed in the 1960’s by Aaron Beck, a psychoanalyst by training who was inspired by Albert Ellis’ Rational Emotive Therapy, Beck recognized where psychoanalysis fell short and created Cognitive therapy based upon his experiences (and frustrations) with his own therapy and with his patients. Later, CBT became both cognitive and behavioral when it merged Beck and Ellis’ works under one umbrella.
CBT which has a cognitive component and a behavioral component- addresses the effects your habitual thought patterns have on your moods, reactions and behaviors. The cognitive component of treatment focuses on helping you identify your particular “automatic thought patterns” which are the recurring negative or self defeating thoughts you have. You are then taught methods for challenging these self defeating thoughts and/ or considering alternative ways of thinking. The behavioral component involves designing situations in and out of session with your therapist (exposure therapy) which will challenge your automatic assumptions by having you face those situations that you fear or that cause you distress.
CBT tends to enjoy more popularity these days due to its having been studied more scientifically and methodically than other therapies and is aptly labeled an “evidence based” therapy. Other therapies can be just as effective- they just haven’t been tested as CBT has and in academic settings evidence based treatments are more widely accepted. What’s great about CBT is that it’s very structured and helps empower clients with its focus on goals and the use of worksheets and strategies. It’s not that other therapies don’t offer “coping tools”- because they absolutely do. It’s just that- in my opinion -CBT markets and packages its offerings a bit better- which can feel clearer to clients and can help them feel they have “something to hold onto” when they leave the therapy office and go out into the world to test out what they’ve learned.
The structured nature of CBT (the fact that there are manuals which are uniformly used by clinicians) also makes it easier to study the effects of CBT- whereas other therapies are not as streamlined – and are therefore harder to unify and then test their efficacy. CBT has also been proven to be very effective in treating anxiety disorders of all kinds, PTSD, substance abuse and OCD.
The Cognitive Component: Automatic Thought Patterns and Self Talk
To give you a better sense of the cognitive component of CBT and “automatic thought patterns”, consider that if we went about our day and decided to pay very close attention to our thoughts- most of us would notice that we operate on automatic much of the day. We say lots and lots of thing to ourselves, about ourselves and others in our heads (aka “self talk”) and assume these thoughts are our reality. For example when you’re waiting for the subway in the morning you might think “I have to get on this train.. I better get on this one!.. darn it why is it crowded! I HAVE to get on this one!” While to some degree this may be true- this is how you’re starting your day- with intense pressure. With annoyance. If you stop for a minute and notice how you pressure yourself.. and if its working for you.. does it carry over into your morning when you arrive at your desk?- you might consider adjusting your self talk (“what can I do.. I’m gonna be late today..”) (and possibly leaving earlier to allow for unanticipated glitches in the morning) so that your day gets off to a better start.
If you stop at moments throughout your day and observe or eavesdrop on your inner monologue you’ll notice how you talk to yourself in your head (kindly? critically? with a negative spin on everything..?) you would likely notice you are often very critical of yourself . For most of us, this is called the “inner critic”. The inner critic actually negates what we want to do rather than motivating us but we don’t always see that. Being unaware of what we’re telling ourselves (it’s like a nasty tape playing over and over) we don’t see how we’re living OUT OF these thoughts/ stories by reacting to them or trying to disprove them, rather than observing what they are telling us and seeing if they are in fact helping us with our goals or our day. Common themes for self talk are : not being good enough, that we SHOULD be doing something we don’t want to do or that we have to keep going because we haven’t done a good enough job yet. Becoming aware of our self talk enables us to then examine its usefulness or lack of and we then can choose whether we want to follow these old tapes or create new ones!
Here’s an example of self talk. Imagine tuning into your mind while sitting in a meeting during your workday listening to someone who impresses you with his presentation. You might be saying to yourself : “wow this guy really knows what he’s talking about.. he sounds so smart… he’s really confident… what’s wrong with me? How come I’m not as confident?… I should be more like him.. I need to read more, I could be just as good as him…!” Suddenly you notice you’re in a bad mood and irritated but without noticing this really self critical story you just told yourself which is your interpretation of a moment in your day about how inadequate you are…You might just be moody and not necessarily know why for a few hours and go home to your family in a grouchy mood. Tuning in this way to your self talk, you can learn about how your thoughts trigger your moods, reactions and even stories you repeatedly tell yourself that make you feel badly all day.
If you look closely you will find that your self talk also has its own themes. We all have various voices in our heads – that can vary depending upon the topic we are thinking about. For example when you think about dating – your self talk may focus on negativity like your body image or how you’re not enough or how the other person is never good enough or how people can’t be relied upon. When you think about your work….often it can be a similar theme of not doing enough… needing to do more…that you should have done better…that you may have made an egregious mistake which then leads you to overwork… Over time you might notice the same theme recurs across many situations. Learning to identify what you are saying to yourself is the first step in making a change. When you become aware of something – it’s no longer automatic and then you can make a different choice.
In CBT, many therapists will complete worksheets with you each session to help you closely examine your thoughts and notice your self talk and how this impacts you and your feelings. This heightens your awareness of how you relate to yourself (and you’ll see- how you also relate to others.. ).
Here’s an example. Let’s say you are a person who is always feeling angry. A CBT therapist might help you track your daily thought patterns by having you complete a log every time you feel yourself getting angry about something. In session, you and your therapist would review what triggered your anger, what thoughts you had about the situation and then how these thoughts affected your feelings (and subsequent behaviors) at that moment. It’s an analysis of a chain reaction of events which as you become more aware of- you have more chances of intervening at earlier points to prevent an explosion.
A client I worked with – let’s call him John- would come into session every week angry about something. He started to realize this in time and said “I’m always angry?! Its all I feel..” In time, as he looked at his patterns he became aware that what preceded his anger was his tendency to set up impossible standards for himself and others. He noticed how he kept unconsciously setting himself up to fail. His worksheet helped him examine the thoughts that led him to explode. Becoming aware of this was an important step in helping him modify his expectations of himself and others. His expectations were often “people should think of me and should always be considerate” When they weren’t he took it personally and would get enraged and this made him feel very unimportant. In truth he was living out a pattern of “I live as if I’m not important… people being considerate confirms my importance” so if people were not- this proved his fear about himself that he was unimportant.
Rather than letting himself feel his sadness and disappointment- John would become angry with others for not being more considerate. The problem with his automatic thoughts and expectations were that people are not always considerate and this thought pattern didn’t leave much room for the inconsistencies of daily life. (Deeper wok using gestalt and psychodynamic therapy was used as well to help mine the core of these issues ie that he chronically feels “unimportant” to others which related to his experience with his father who could never give him approval and never made him feel important as his son).
Another example might be if you’re anxious and you worry what other people are thinking of you if you voice your opinion or assert yourself. Your self talk might be “is he mad? Did I say the wrong thing?”. A CBT therapist might use a technique known as Socratic questioning- which is a particular style of asking questions such as: what are facts and what are simply my perceptions? Am I using any thinking errors here (CBT offers a list of “common thinking errors” such as catastrophizing, personalizing, generalizing etc..)?How else can I view or perceive this situation? how do I know for sure what he’s thinking? What evidence do I have for that thought? And if that were true then what? And how would I cope with that if it were true?” Getting to the bottom of your worst fears can help you discover you actually might cope better than you anticipated which might in turn decrease your anxiety. Overall, practicing CBT can help you develop a more flexible approach to life by helping to flex your thinking and your sometimes stubborn beliefs!
The Behavioral Component
The behavioral component of CBT involves collaboratively designing situations with your therapist for you to practice both in and out of session (also known as “exposure therapy”) which challenge your automatic assumptions by having you face those situations that you fear. This part of therapy is very effective in helping people master their anxieties and regain their lives. Exposure is focused on behavioral change and very useful in that often it is the only thing that helps a person make the shift from talking to action. In many situations, it is in the experience that we change as opposed to in the talking about how to change.
When someone is frightened of social situations- while it can be useful to discuss these fears and examine their beliefs and what feelings these situations evoke for them, the bottom line is that until they can find ways to test out their beliefs and challenge their anxieties they may struggle to make meaningful changes in their life. These issues will often remain unchanged because the person’s fears and assumptions remain unchallenged. By creating what we call a hierarchy (a list of feared situations), the client (with therapist assistance) is put in charge of setting up gradual experiments/ situations with he will face at his own pace in order to learn to bear his anxiety until it eventually decreases. This process is called habituation and is crucial in helping clients gain more control over their phobia or feared situation rather than remaining a victim to their fears.
One client I worked with struggled with social phobia. He had a great deal of trouble talking to or being around people. One particular fear he had was that his hands would shake when he was writing a check in the supermarket and people would see how anxious he was and he think he was mentally ill - which would feel intensely embarrassing. Or he feared, they would get angry at him and yell at him for taking so long which would also feel humiliating to him. He was certain of his fears and beliefs about this. In addition to cognitive work on his thought patterns which involved considering other possibilities for what people might think of him such as “maybe he has parkinsons… okay maybe he’s just nervous so what?.. maybe he’s on medications that make him shake....” – we worked behaviorally by setting up an exposures for him to write checks several times each week in various local supermarkets to help him – “in vivo” (live) experience his worst fears.
The principle behind exposure is “habituation” meaning that if you hang out long enough with your anxiety it will decrease and you will then learn you can manage. It has been compared to going into a pool and initially feeling very cold and uncomfortable until your body adjusts to the temperature. Practicing these repeated exposures with this client in conjunction with implementing the cognitive coping we worked on to challenge his beliefs, he learned to overcome this fear and is now able to write checks in public without any difficulties.The upside of CBT is that it can help you learn the “how to” in changing unwanted behaviors rather than just keeping you on the why. While most therapies share their belief that awareness will set you free, oftentimes clients are unable to move further and take the next step to making the changes they so wish to see and behavioral work is essential in this way.
So… while I am a huge proponent of CBT and use it regularly in my practice, I am also very much interested in continuing to integrate other modalities to provide my clients with the combination of the most effective therapies I myself have grown from. Sometimes CBT is enough, but sometimes deeper work is needed on understanding the origins of these beliefs and how they have come to serve some function in your life.