Cognitive Behavioral Therapy
An in-depth explanation
Cognitive-Behavioral Therapy (CBT) has been proven both clinically and by numerous research studies to be an effective form of treatment for many psychological conditions. These include anxiety disorders such as panic disorder, shyness and social anxiety, phobias, OCD, generalized anxiety, PTSD, depression, low self-esteem, substance abuse, and relationship problems. CBT is what I refer to as “emotional education” in that the therapist serves as a teacher, tutor and coach to provide a great deal of information about emotional functioning. CBT combines two effective forms of treatment: Cognitive therapy and Behavior therapy.
Cognitive therapy: Cognitive therapy focuses on identifying, challenging and modifying the individuals negative, anxiety-provoking cognitions (thoughts). These thoughts are also referred to as anxiogenic cognitions – meaning anxiety generating thoughts. These thinking patterns cause the symptoms of anxiety, depression and low self-esteem, and contribute to behavioral problems such as overeating and substance abuse. It is difficult for an individual to identify their own irrational and negative thought patterns, and more difficult to change them even if identified. It requires the assistance of a knowledgeable therapist to help identify and modify these thinking patterns. When one is feeling negatively, it is often because they are thinking negatively. These negative thoughts are often out of line with reality in that they are more negative than realistic. These negative thinking patterns are also referred to as irrational as opposed to rational, because they are unrealistic, and unrealistically negative. Therefore, as I often stress to patients, thinking more rationally is not positive thinking, it is simply more realistic thinking which happens to be more positive than their usual irrational and negative thoughts. The problem with the notion of positive thinking is that it often strikes people as pie-in-the sky, overly optimistic, hopeful, and temporary thinking. Rational thinking is more positive, is reality based and not just optimistic, and can therefore become permanent thinking.
Cognitive therapy with Panic Disorder focuses on identifying fearful beliefs about the physical, or somatic, sensations being experienced that become intensified due to a process called SOMATOSENSORY AMPLIFICATION, resulting in anticipatory anxiety that escalates to panic and agoraphobic avoidance. Critical to cognitive therapy with panic is the identification of the CATASTROPHIC MISINTERPRETATION that are responsible for the escalation of fearful thoughts into full-symptom panic. In contrast, cognitive therapy with Social Phobia involves identification and modification of the core fears of negative evaluation by others, as well as the beliefs and avoidant behaviors that prevent disproving those assumptions. The identification, challenging and modifying of these beliefs are part of cognitive-restructuring.
Behavioral therapy: Here the treatment focuses on modifying behavior to aid in modifying underlying cognitions, beliefs and thinking patterns. This process helps to lessen the connection between situations and reactions to those situations, and reduces the intensity of those automatic reactions. This is an active and collaborative therapy. By this meaning the therapist is actively involved in the therapy vs. passive and merely providing support while the patient works to figure out their problems. It is also a collaboration between the therapist and patient as they devise behavioral strategies and work together in their implementation. The behavioral treatment or testing of assumptions, involves desensitization and exposure techniques. Desensitization procedures involve the use of fantasy to imagine and rehearse the successful management of a frightening situation while in a relaxed state. This is in vitro desensitization, which helps to facilitate more successful management of the stressful situation in real life, or in vivo exposure. So desensitization techniques use imagery to imagine and master situations in the minds eye. Exposure techniques incorporate experiencing the feared situations, either in a controlled manner in the therapy session called interoceptive exposure, or in real life: in vivo exposure.
Benefits of CBT: One of the most prominent benefits of CBT is the strong maintenance of treatment progress. In other words, the benefits of CBT are long-lasting, unlike medication that is of benefit only as long as it is used. CBT helps people “unlearn” their fears and avoidant behaviors, and new learning occurs: the learning of relative safety in relation to the original feared situation. There is also strong evidence that exposure techniques in CBT are more effective when the therapist also helps the individual recognize their SAFETY BEHAVIORS. These are behaviors the individual with anxiety engages consciously and unconsciously to help them avoid their imagined catastrophic fate when confronted with their feared situation.
CBT vs Medication: Many studies have demonstrated the superiority of CBT over medication alone in the treatment of anxiety disorders. Some studies have shown an additive value in the use of medication along with CBT but other studies have demonstrated no additional benefit to addition of medication to effective CBT. It appears that there is benefit in adding exposure techniques to the treatment of an individual already on medication, and less value in adding medication to the treatment of an individual engaged in CBT. The benefits of such combined therapy seem to disappear when medications are discontinued. Two large scale studies provided strong evidence that once medication was withdrawn, individuals on combined therapy did worse than those receiving CBT only. It is the longer term maintenance of treatment gains that truly makes CBT alone a more effective form of treatment. It appears that CBT alone is superior to combined CBT and medication due to the impact on learned safety behaviors. Research shows that “safety learning” (or learning to challenge and disprove the catastrophic hypothesis) as opposed to safety behaviors, occurs with exposure techniques. The use of medication undermines the effectiveness of safety learning, as the individual attributes much of their success to medication, another safety behavior. When the medication is removed, the return of fear is likely. Despite these disadvantages, some individuals need medication to bring their anxiety down to manageable levels to facilitate CBT. When it comes time to discontinue medication, additional therapy, both CBT and supportive, are important to complete the internalization of safety learning. And some leading experts such as Dr. David Burns recognize such downside to combined drug and talking therapies that he advocates tapering off a sedative medication such as Xanax or Klonopin before beginning CBT. He also believes there is no benefit to SSRI antidepressant medication and cites many studies that have demonstrated antidepressant medications to be no more effective than placebo. There is growing evidence and general knowledge of this, including the unethical lengths the pharmaceutical industry has gone to skew research studies and even suppress studies that demonstrate these facts.
GENERAL COGNITIVE MODEL:
“AUTOMATIC THOUGHTS & IMAGES”
PHYSIOLOGICALIn other words, a situation such as a thumping heart; causes automatic thoughts and images such as the thought of a heart attack and images of having a heart attack; causes a reaction both emotional (fear, terror, panic), behavioral (looking for help); and physiological (further palpitations, light-headedness, feeling faint, sweating, flushing).
CBT focuses on helping the individual identify their situations, thoughts and images, or what I refer to as the “thought-feeling” chain. By identifying ones chain of thoughts and feelings that culminate in a panic attack, an individual is empowered to intervene in that chain and abort a developing panic attack. When these anxiogenic (anxiety producing) thoughts are identified, CBT helps the individual challenge their rationality/feasibility, and modify/eliminate them. I use an Anxious Thought Record to help the individual complete this exercise both in the therapy session as well as on their own.
ANXIOUS THOUGHT RECORD
- WHAT IS THE FEARED SITUATION?
- WHAT IS THE NEGATIVE/ANXIOUS THOUGHT?
- WHAT IS THE FEARED CATASTROPHE? (SPECIFIC!)
- WHAT PERCENT DO YOU BELIEVE IT TO BE TRUE? (0-100%)
- WHAT FACTS SUPPORT FEARED CATASTROPHE?
- WHAT FACTS SUPPORT NON-CATASTROPHIC EXPLANATION?
- WHAT PERCENT DO YOU NOW BELIEVE THE CATASTROPHIC FEAR TO BE TRUE? (0-100%)
This exercise is difficult initially without therapeutic assistance, because many of the thoughts and images are difficult to isolate and identify on one’s own. With therapeutic assistance one comes to recognize their pattern and develop the capacity to more successfully engage this process on their own.
The following are common irrational, negative and self-defeating thoughts and patterns of thinking that contribute to negative feelings: anxiety, depression, anger and guilt. These thoughts and thinking patterns also contribute to relationship and behavior problems. The identification, challenge and modification of these negative, self-defeating beliefs constitute a significant part of CBT.
- All or Nothing Thinking – You look at things in absolute, black and white categories.
- Overgeneralization – You view a single negative event as a never ending pattern of defeat.
- Mental Filter – You dwell on the negatives and ignore the positives.
- Discounting Positives – You insist your positive qualities don’t count.
- Jumping to Conclusions – You jump to conclusions not warranted by the facts.
- Mind Reading – You assume that people are reacting negatively to you.
- Fortune Telling – You predict that things will turn out badly.
- Magnification or Minimization – You blow things way out of proportion or shrink them.
- Emotional Reasoning – You reason from your feelings instead from logic. For example: “I feel like an idiot so I must be an idiot.
- Should Statements – You think in terns of “should, shouldn’t, must, ought and have to”.
- Labeling – Instead of saying “I made a mistake”, you tell yourself “I’m a loser, jerk, idiot” etc..
- Self Blame and Other Blame –
- Self Blame: You blame yourself for something you weren’t entirely responsible for.
- Other Blame: You blame others and overlook ways you contributed to the problem, thereby reducing your sense of power.
Once a person has become familiar with and has had success with the 1-2-3 method, they can begin to use a condensed form of it with “Stop”. Here you begin to compress steps 1 and 2 into one step to more effectively accomplish the 3rd step of refocusing. Some people find they are compulsively repeating steps 1 and 2 but the thought or a new thought comes in and they are again repeating the steps with the new thought. They have not been able to get off the mental hamster wheel and refocus with a new thought or activity. By only doing steps 1 and 2 – thinking about the irrational thought – they are still giving it energy and power. Freedom only comes by activating a different neural circuit and refocusing. So to end the mental debate with the irrational brain, or quit dancing with the devil, a simple command can be very effective – you compress the first 2 steps into one with a simple command to yourself (take your pick or find a new one):.
“SHUT UP” (maybe even “shut the ef up”)
By this command you have effectively diminished or even dismissed the sense of threat to now allow you to refocus – again on something present, pleasant, real, interactive with others and/or physically engaging. You are truly diminishing the power of the fear habit and reducing the amount of time required to free yourself so you can get on with your life – controlling the anxiety instead of it controlling you.
When your limbic system throws another fearful thought at you, it helps to command it to stop. This is very different from the self-distraction that most people tried before they learned about the 1-2-3. That type of distraction didn’t work because you hadn’t labeled and discredited the threat in the first place, so it was hard to focus elsewhere when you just KNEW that a freight train was heading at you. By learning 1-2-3 you know it is a malfunctioning in your brain – now what you need to do is activate another part of your brain to quiet the false alarm in your head.
Resisting old bad habits is hard. Very hard. It is very difficult to completely surrender an old ingrained pattern of behavior such as biting fingernails or smoking cigarettes and perhaps more difficult to resist or break ingrained thinking or feeling habits. Once a habit is learned, it is permanent learning stored in the brain’s limbic system. You can never forget how to ride a bike for example. Likewise, an alcoholic or addicted cigarette smoker will never be able to become a controlled moderate user. The old habit will again prevail. That said, an old habit can be put into remission by resisting it and replacing it with a new good habit. The Timeout Technique is simply making yourself hesitate a bit before acting on the urge. In AA they talk about taking it a day at a time, sometimes an hour at a time, sometimes a minute at a time. The point is that by inserting a small time break between stimulus and response; between the urge and follow-through, you increase your capacity for resistance. When we have an urge to do something waiting a bit before acting decreases the urge and increases our capacity for self-control. Telling ourself to wait 10 minutes, or even 1 minute, before we act can help us resist altogether.
This is especially applicable with the vicious cycle of OCD or similar in other anxiety disorders. When an obsessive, intrusive thought occurs it causes distress and triggers an urge to do a compulsive behavior to reduce the distress. While the compulsive act may briefly reduce the distress, it is always short lived and only perpetuates the problem. The obsession causes the compulsion and the compulsion reinforces the obsession. The point of intervention is with the behavior – the compulsion – whether it is an actual physical behavior or a mental act such as counting etc. The brief decrease in distress by performing the compulsion perpetuates the obsession which will reoccur and therefore trigger a compulsive urge again. The more you do it the more you will do it – the insidious nature of all bad habits.
So for example: if a hypocondriac is experiencing a physical symptom and is fearing it is catastrophic, such as cancer, and chooses once again to Google the symptom, their fear may be briefly reduced but it will return. If a person has the obsession whether the door is locked and check it 3 times, their distress is only briefly reduced. Cooperating with the irrational fear in the first place intensifies it and can lead the person to needing to check the lock 4 times, then 5 times, etc. In these examples, the Timeout Technique is to take at least one minute, preferably more, before they allow themselves to act on the irrational urge. Even if they only delay one minute, they’re already beginning to insert a time break between urge and action – it can then be expanded upon to reduce and break the old bad habit. Though resisting immediate cooperation with the irrational urge causes an immediate increase in distress, that distress will start to come down. Doing so repeatedly will over time decrease the power and frequency of the intrusive fear, just as by cooperating with the fear increases the frequency and power of it.
“THOUGHT REPLACEMENT” and “HABIT REVERSAL” TRAINING
Habits and addictions are very difficult to overcome because they are self-reinforcing and self-perpetuating. The more you perform a habit the stronger it becomes so you will do it more and make it stronger. The neurotransmitter Dopamine plays a significant role in this dynamic. Part of why we act on a habit is that it releases dopamine, and dopamine makes you want to do it again. It’s not so much that dopamine creates a sensation of pleasure but that dopamine stimulates the urge to repeat the behavior that released dopamine. We are fighting our brain chemistry is fighting habits, but these are techniques that makes it easier. Here it is important to understand the 3 components that comprise all habits:
- Cue – the trigger to start an automatic behavior;
- Routine – the behavior itself;
- Reward – how the brain learns to remember this pattern for the future.
The golden rule of Thought Replacement and Habit Reversal Training is to work on modifying #2 – the routine itself. The cue and reward don’t change. Thought Replacement focuses on changing repetitive thoughts while Habit Reversal changes repetitive behavior. They both work to accomplish the same outcome of reducing habitual activity – mental or physical.
An example with a physical activity would be to recognize the sensation to chew your fingernails and modify the routine by sitting on one hand and do a new behavior with the other e.g. rap knuckles on the table, or rub your arm, or tap your finger on the desk, leg or whatever. This creates a physical sensation that substitutes for the fingernail biting sensations. Only the routine was changed. There are limitless variations that can be created to modify the routine.
An example of modifying mental activity with “Thought Replacement” was a young student who was in class and was annoyed with a repetitive thought. He used an example of what I had explained: he started tapping his finger on the desk while counting the taps until the intrusive thought was stopped. It took him 62 taps to stop the thought. Another was a client who described exercising alone in the basement and his brain started repeating a thought. He used this technique to willfully choose a line from a song that was playing and repeat it for a few minutes – the automatic intrusive thought was therefore silenced and went away – it was replaced. He was then able to choose to stop repeating the song lyric – he was in control – not the OCD brain.
Chronic worry, fear, obsessions and compulsions are all habits. Bad habits. They can cause so much suffering and interference with ones life that they could even be considered addictions. But despite the nature of or cause of the bad habit it can be broken and replaced with a new good habit. The process of resisting the powerful urge of the old habit and working to create a new good habit is very difficult. While bad habits are effortless, fast and powerful automatic thoughts or behaviors; the new habit is created by purposeful, deliberate, mindful and intense conscious effort. The old habit occurs automatically but the new habit has to be created with much effort.
There have been significant advances in brain science in recent years including better mapping of which parts of the brain are responsible for different functions. Our primitive brain, the limbic system, is very powerful because it is primitive – it is responsible for our very survival. The fight or flight or freeze response is activated in the limbic system, and it is where our emotional memory is stored – especially the memory of fear. As such, anything that reminds us of fearful experiences can trigger a strong fear response even though the fear is not justified by the external reality. Therefore fear responses come quickly and become a bad habit. The limbic system is what I refer to as the feeling brain whereas the more recently evolved prefrontal cortex is the part of our brain that allows us to think rationally, not simply react emotionally, and is the part of the brain I refer to as the thinking brain.
To retrain your brain and turn down/turn off the feeling brain and turn up/turn on the thinking brain when struggling with obsessions, compulsions or chronic worries and fears, you need to learn and use the following 3 step method:
The “1-2-3” method
The 1-2-3 method is a very powerful and condensed use of Cognitive Behavioral Therapy that activates the circular relationship between thinking and behavior. The goal of 1-2-3 is to actively engage and empower the thinking brain to reduce the power of the feeling brain and modify our behavioral response. This method is a blueprint for CBT and guides you through the steps required to reduce automatic feeling responses and increase rational responses. This leads to greater peace of mind and feeling of self-control.
STEP 1: LABEL
When you are experiencing anxiety the first thing required is to be able to recognize and label what you are experiencing. You need to label it, for example, say to yourself, “This is just my anxiety”, or “This is my fear habit again”, or “This is me catastrophizing again” or “This is my what-if thinking habit again”. This is very powerful because it is you now having a rational thought about the automatic fearful feeling and thought. It automatically is activating more of your thinking brain to have a clear thought about what you are experiencing – a clear thought about the silly thought. I compare this to the first step in AA and the 12 step programs – being able to recognize and accept one’s addiction. There are many labels that you can use, including:
- This is an obsession
- This is a compulsion
- This is my OCD
- This is my hypocondriasis
- This is my worry addiction
STEP 2: DEVALUE
In this step you “talk back to the fear” with rational ideas that help to devalue and discredit the original fearful thought and feeling. You rationally and realistically tell yourself facts as to how the fear is not as significant as your feeling state tells you it is. You remind yourself of facts such as:
- These fears never actually happen
- I always exaggerate these things
- If something like this did happen I know I can handle it
- I have handled frightening situations in the past
- I don’t ever truly loose control of myself
STEP 3. REFOCUS or REplACE
This is the most important step and change won’t occur until you can shift your thoughts and attention from the intrusive thought and resist doing what the feeling brain wants you to do and instead do something else. This step is completely different from the typical distraction that everybody with anxiety attempts because you had not sufficiently discredited the fearful threat to allow distraction to work. Here you have reduced the belief in the threat to a degree sufficient enough to allow yourself to shift focus. Things to do to refocus include:
- Shift attention to the present moment (be present in the present)
- Think about and/or do something pleasant or pleasurable (the more positive it is, the more effective it is)
- Focus on your reality – where you are, who you are with, what you are doing – the more engaged you become with others, the more your attention will be redirected.
The more active the new activity, the more it will refocus you and generate different neural activity.
The effect of doing the 1-2-3 is that it begins to reduce the habit of automatic surrender to fear and begins to develop a new good habit of separating from and reducing the power of fear. It is difficult because it requires conscious effort while the fearful feelings and thoughts come automatically. But with conscious effort it can be done and helps to retrain the brain. By activating new thoughts, behaviors and feelings in response to an old stimuli, you are actually changing your brains functioning. You increase activity in the prefrontal cortex (thinking brain) and decrease hyperactivity in the limbic system (feeling brain). As with all habits, they are self reinforcing. The more they’re performed the more they will be performed. The new good thinking and feeling habit will come quicker and with less effort the more they are performed.
- Spend only a little time on #1 and #2 – you don’t want to spend too much time with the content of your fear – it only gives it more energy or power.
- Spend a lot of time, the rest of your time ideally, on #3 – refocused on something else – positive, in the present, and even better if it involves another person or doing something other than repeating the compulsive action.. You need to do something else to shift mental gears. Use it or lose it – the less time you spend thinking about the fear the less you deepen the obsessive brain circuit.
- Remember – it’s not what you feel when pushing away from the obsessive thought or compulsive urge – it’s what you do. The struggle is not to make the feeling go away but to not give in to the feeling.
- Also – this takes hard work, over time – but it can lead to new brain circuits.