Wouldn’t you like to stop your stressful, anxious thinking in its tracks? Turns out you can, and while you’re at it, you can make yourself feel and act better too.
That’s the basis of cognitive behavioral therapy, which burst onto the psychological scene in the 1960s and has been gathering accolades ever since.
According to the National Alliance on Mental Illness, CBT, as is it called, is designed to “uncover unhealthy patterns of thought and how they may be causing self-destructive behaviors and beliefs.”
It may not be for everyone. Therapists typically assign “homework,” so it takes active participation on the part of the client, and it doesn’t address underlying issues such as childhood trauma or systemic problems in families.
But for those willing to put in the work, cognitive behavioral therapy can be just what the doctor ordered. CBT has been shown in randomized clinical trials to ease depression, anxiety, obsessive thinking, eating and sleep disorders, substance abuse, post-traumatic stress disorder and more.
Just what happens during CBT that can produce change in such a wide variety of conditions?
In a nutshell, what is cognitive behavioral therapy?
Jay Fournier: It’s a structured kind of psychotherapy, much different than the type of therapy often portrayed on TV or in the movies. The focus is on trying to help people get well as quickly as possible by reducing their symptoms as quickly as possible.
CBT tends to focus more on the present than the past, and is typically a shorter-term treatment. The first few sessions with a cognitive behavioral therapist will home in on your goals: What is bothering you and what do you want to change? Then we will set up a treatment plan designed to address those goals within a certain period of time.
My job as a cognitive behavioral therapist is to put myself out of work. I’m trying to train a person to do all the things that I know how to do in their own lives, so that when we stop meeting they can continue doing it without my help.
In CBT, how do our thoughts affect our actions and feelings?
Fournier: Most folks go through life thinking that the way that they feel or the things that they wind up doing are directly influenced by what has happened to them in their lives. One of the core elements of cognitive behavioral therapy is that there’s an intervening step: How we interpret those situations. It’s our interpretations of those events that lead us to feel certain things and behave in certain ways.
One of the first things we would have people do is just notice their thinking. If you notice your mood changing, try to ask yourself, “What was going through my mind right before I felt worse?”
The goal isn’t to think happy thoughts because happy thoughts are fun. The goal is to help people think more carefully and accurately about their circumstances, particularly folks who have a tendency to think more negatively when things get harder.
Let’s use the example of someone calling you a name. You might think, “That person saw right through me, they’re exactly right, I am just that.” And you’re likely to feel pretty terrible about yourself. Or you could think, “Wow, that person is such a nasty person. I really have to evaluate whether I want them to be in my life.”
Most of us aren’t terribly aware of thinking such negative thoughts, just the bad feelings. How does CBT help people become more insightful?
Kristen Carpenter: We do a lot of training around identification of automatic thoughts and the beliefs that underlie them. It starts with identifying self-talk — literally the things you say to yourself in a moment of distress.
The thoughts that we typically see in those who are depressed, for instance, tend to be around these beliefs: “I’m unlovable; I’m unworthy; the future is dim, and there’s very little I can do about it.”
For those who are anxious, those core beliefs tend to be around threat: “The world is scary; the world is threatening; I am not equipped to face these challenges.”
As therapists we help you analyze your self-talk with a series of questions: “How true is that thought? What evidence do you have for and against that thought? How realistic is it? Are there thinking errors that we can identify? And it’s not just people with a clinical diagnosis that make errors in thinking — we all do that.
Some of those thoughts might be logical fallacies. Others are what we call “should” statements: “I should be able to work full-time and also help my kid with their homework every night and have a rich and engaged social life and be well read, and get to every event that has ever occurred and cook healthy meals.”
We help the person begin to question some of those statements, and evaluate how realistic they are. Many of us hold ourselves to higher standards than we would hold others to: “Why does every other mom in the block get a break but you don’t?”
But it’s not shifting negative thinking to a “rose-colored glasses” approach, because that doesn’t really help either. It’s too far. What you want to do is pull toward the middle, toward the kind of thinking that is compassionate to the self, that is more realistic and is not bound by assumptions that might be false.
At the end of the day what we’re doing in CBT is helping modify false, exaggerated beliefs, so that people learn the skills they need to overcome negative self-talk.
I understand that CBT often has homework. What type of homework do you assign?
Fournier: Cognitive behavioral therapy does involve homework, and a lot of that homework is paying attention in a new and different way to what you’re doing, how you’re feeling and what’s going on in your mind.
In the course of therapy, we would have specific worksheets that we might hand out to folks, and there are apps they can download to do the same. Eventually, we want people learn to use these tools on their own. We think of CBT as a collaborative relationship, where we’re working together to bring about the changes in the person’s life that they want to see.
One major tool we use is called an automatic thought record, where people keep track of what they are doing, thinking and feeling during the days between sessions. They’ll bring it back to the session, and we’ll go over it together and evaluate the thinking. What doesn’t make much sense? What are alternatives ways of thinking or handling the situation?
We also ask people to keep track of their stress and anxiety levels. And then together we look for spikes: “When were you feeling the most stressed? The least stressed? What were you doing and thinking?” And then those would be the things that we would start to focus on in treatment.
We’ve talked a lot about the cognitive side of CBT. What about the behavioral side?
Carpenter: CBT is predicated on the assumption that thoughts, behaviors and emotions are intertwined: “My thoughts influence my feelings, my emotions influence my behaviors, and it’s all interrelated.”
As a therapist, that gives me three pathways I can use with individuals to help effect change — via thoughts, emotions and behaviors.
Take depression, for example. Depressed people withdraw from the world, no longer doing things they once found pleasurable and enjoyable. For somebody with those kinds of challenges, we would encourage them to schedule positive activities, reach out to friends and family, and try to do things that will give them a sense of belonging or a sense of accomplishment.
Can these behavioral changes apply to stress, such as the stress and anxiety that the pandemic has caused?
Fournier: When folks struggle with anxiety they tend to avoid the things that they’re anxious about. It’s pretty natural behavior. But avoidance can interfere with life, can interfere with their goals for themselves, and they can ultimately wind up making the anxiety worse. And so in anxiety, the treatment is helping them gradually reapproach the situations they’ve previously been avoiding.
For people experiencing high levels of stress, well, some of those things are changeable in people’s lives, but some of them aren’t, especially during the pandemic. Depending on the circumstance, we might encourage folks to make the changes that they could make.
But even for the anxiety-causing life moments they cannot change, we can look at how they’re experiencing those situations.
Sometimes bad things happen in life, and that’s just part of it. But sometimes people experience more depression or more anxiety than the situation necessarily calls for. We can help them take a look at their thoughts and behaviors during those periods to see if there are ways to change those thoughts to reduce their stress.
While I’m not an expert in post-traumatic stress disorder, CBT has been shown to be very helpful with symptoms. Of course, we can’t change the past; we can’t change what happened to the person. But what we can help them do is change their relationship to what happened to them, by changing their thinking about the traumatic experience. By doing that, we hopefully help them experience fewer life-interfering symptoms associated with the trauma.
How can a person find a trained CBT counselor?
Carpenter: I always recommend the Association for Behavioral and Cognitive Therapies. They have a listing of therapists who are CBT-trained and you can look locally by zip code. The American Psychological Association also lists CBT-trained therapists under “treatment methods” in their “Find a Psychologist” mechanism.