Cognitive Behavioral Therapy

Cognitive behavioral therapy, often referred to as CBT, is one of many different types of talk therapy. It was developed back in the 1960s by a psychiatrist, Dr. Aaron Beck. In his clinical work with patients Dr. Beck began to notice a distinct connection between a person’s thoughts and feelings. He also noticed from his work that people usually have a set of beliefs or attitudes which dictate their thoughts. Additionally, patients who were struggling with depression and other disorders often engaged in various types of maladaptive thoughts or “thinking errors”, such as jumping to conclusions or all-or-nothing thinking.

As humans we tend to act based on our feelings. By learning to identify and challenge thinking errors and erroneous beliefs we can begin to make changes which will positively impact our feelings and actions.

Disorders Treated with CBT

Over the past several decades CBT has become a very widely used type of psychotherapy. Dr. Beck used it extensively to treat patients with major depression, but it can also be very effective for a variety of disorders or issues including, but not limited to:

• Anxiety

• Panic disorder

• Posttraumatic stress disorder

• Obsessive compulsive disorder

• Substance abuse or addiction

• Problems with sleep

• Relationship problems

• Chronic pain

• Anger problems

• Eating disorders

• Phobias

• Social anxiety disorder

A Closer Look at Cognitive Behavioral Therapy

The name “Cognitive Behavioral Therapy” stems from the fact that 1) its primary emphasis is on thinking, and 2) elements of behavioral therapy are also utilized in the process. There are different types of CBT, such as Dialectical Behavior Therapy (DBT) and Rational Emotive Therapy, to name two.

Unlike psychodynamic therapy models which focus on unconscious processes, CBT focuses on people’s thoughts, attitudes and beliefs – our cognitions. A CBT therapist will help a person understand how those cognitive processes affect how he or she handles emotional problems, views situations, and behaves. For example, a woman struggling with depression may have the belief that she is worthless. This belief significantly impacts her thoughts, her reactions to various situations (e.g., “Of course he didn’t want to go out with me again – I’m a loser!”) and her feelings (e.g., hopeless, sad, bitter). As a result of these thoughts and feelings, she may behave by keeping herself very guarded on a date. This tends to create a vicious circle, reinforcing her negative (but erroneous) belief.

The therapist will likely have her look at her past and find all the ways in which she has been a winner in some way or another – thus challenging the validity of her underlying belief. The therapist will also have her come up with other possible explanations as to why the man didn’t ask her out again. For example, perhaps the man thought she wasn’t interested, or met someone else with whom he had more in common, or because she resembled his ex-wife and that made it uncomfortable for him. All of those possible reasons have nothing to do with her being a loser.

Automatic Negative Thoughts in CBT

A key tenet of CBT is the idea of automatic thoughts. These are thoughts which are fraught with emotion and tend to automatically come to mind in various situations. To use the example above, the thought “I’m a loser – no man ever wants me!” is very likely an automatic thought which the woman often has whenever something goes wrong or someone rejects her in some way. Rather than consider all the other possibilities, she automatically concludes bad things happen because she is a “loser” and men never want her.

Often, people don’t even realize how many automatic thoughts go through their mind every day. Beck noticed that these thoughts were typically negative if the person was angry, hurt or upset about something. Also, the automatic thoughts weren’t usually realistic. And they usually made the person feel worse. CBT helps the person recognize these automatic thoughts and challenge their validity, as these thoughts are what cause painful feelings.

It’s Not the Situation, But Our Reaction to It

As Beck realized, it is not the situation which makes a person upset, angry, hurt, or panicked; rather it is the thought we have about the situation – the meaning we assign to it. If the woman in the example above had given a different meaning to not getting asked out again by the man, she would have had a different emotional response.

For example, if she had interpreted his behavior to his impression that she wasn’t really interested (and therefore he didn’t think she would even go out with him again), she would likely have been much less upset. In fact, she may have sent him an email after the date letting him know that she had a great time and would really enjoy getting together again.

As you can see from this example, our thoughts about any given situation significantly influence both our subsequent feelings and behaviors. By changing those thoughts (and corresponding beliefs) to more adaptive ones, we are going to feel better in general.

Types of Cognitive Errors

CBT focuses on helping you change the habitual errors in your thinking. Many of our thoughts are automatic reactions to various types of events. The premise of CBT is that by identifying these thinking errors, challenging their validity (and looking at how they don’t serve you), and changing them to healthier ways of thinking, you will feel better (i.e. less depressed, less anxious, etc).

There are several different types of cognitive errors outlined in CBT. These include the following:

1. “Should” or “ought” statements – This occurs when you have rigid rules for or put unrealistic expectations on yourself or others. For example, “I should be able to….”, or “People should never .…”. These types of statements will leave you frustrated, angry, disappointed, or resentful. In CBT, you might be asked to reframe these statements into what you would “prefer”, recognizing that you cannot control everything.

2. Labeling or mislabeling – This type of thinking involves placing labels (or mislabels) on yourself, others or situations. For example, “He’s an idiot”, or “I’m a total loser”. Rather than focusing on the actual behavior, labels focus on identity. They are also absolute and usually negative. In CBT you would be asked to focus the behaviors or actions, for example, “What exactly did he do that was idiotic?” Also, remember that behaviors don’t define you or anyone else: “I made a mistake, but that doesn’t make me a loser”.

3. Emotional reasoning – This occurs when you argue your position or make decisions according to your feelings rather than fact. When this type of thinking occurs, it can be very difficult to differentiate between emotions and reality. For example, “I feel stupid, so I must be stupid”. It wouldn’t matter if you had just been accepted to Harvard Law School your emotional reasoning would override the blatant fact that a “stupid” person would never get into Harvard.

In CBT, you would work on trying to come up with things that validate your flawed reasoning, or things which contradict it.

4. All-or-nothing thinking – This is also known as “black and white thinking”. When you use absolute or “black and white” terms such as “always” (e.g., “I always fail”) or “never” (e.g. “I never get a second chance”), you are engaging in this type of thinking. In CBT, the goal is to challenge the absolute statements.

For example, a CBT therapist would ask you to make a list (i.e. provide evidence to the contrary) of all the times you didn’t fail; i.e. all the times you have succeeded. You can begin saying to yourself, “Sometimes I do fail, but many times I succeed”.

5. Jumping to conclusions – Most of us do this occasionally. But have you ever jumped to a conclusion and became very upset, only to find out later that your conclusion was completely wrong? If you assume that a friend didn’t call you because she was mad at you, you might get upset or react defensively. In CBT you would list other possible reasons she didn’t call, such as she’s been working overtime on a project, or had company drop by, etc. When people jump to conclusions frequently, rather than giving others the benefit of the doubt or checking out the facts, they end up causing themselves a lot of unnecessary stress.

This category also includes “mind reading” and “fortune telling”. An example of mind reading would be assuming your girlfriend would prefer to date another guy simply because you observed her chatting with him briefly at lunch.

Using this same example, fortune telling would involve your assumption that, since she was chatting with him, she is going to break up with you in the near future. In CBT you would be challenged to consider what evidence you actually have for either of these things, and to consider other possible scenarios or outcomes.

6. Overgeneralization – This thinking error occurs when you take one incident or a few bits of information and turn it into a sweeping generalization. For example, you submit a story to a magazine and it’s rejected. You quickly conclude, “I’m no good at writing so why bother?”. CBT would help you realize that one incident doesn’t mean it’s going to be a pattern if you continue trying.

7. Magnification or minimization – This type of thinking occurs when you blow something completely out of proportion (magnification) or discount (minimize) other things. For example, “All my friends are incredibly smart and attractive, and I’m stupid and ugly”. In CBT you would work on challenging those extreme statements and putting them into more realistic perspective.

Catastrophizing is a type of magnification. For example, you get reprimanded at work by your boss for a mistake you made, and from that you become certain that you are going to lose your job, your career is over, you’re going to end up homeless, etc. In CBT you would work on challenging the likeliness of such extreme outcomes.

8. Disqualifying the positive – This thinking error occurs when all you can see are the negative aspects of a situation, while completely rejecting, or “disqualifying”, any positive aspects. You are convinced that if something did actually go right, it was luck, or a fluke. You may often respond with “Yes, but…” whenever someone else tries to help you see the positive.

For example, your boss critiqued a project and gave you positive feedback overall, but had some constructive criticism for one aspect. You take that and say, “I completely messed up on that project; my boss hated the part about____.” In CBT you would work on considering all the things your boss liked about your project, and putting the other in appropriate perspective.

9. Blame or personalization – This occurs when you feel responsible for things which are completely beyond your control, or you blame others for your problems or bad things happening in your life. For example, if your child gets into a fight at school, you conclude, “It’s my fault for not being a better parent”. Or, “If my parents had been better role models, I would be more successful in my career”.

In CBT you would be challenged to consider, for example, how it is you are to blame for your child’s behavior, or how you may have contributed to your lack of career success.

10. Filtering – this is very similar to disqualifying the positive. For example, you prepare a dinner for friends and everything is spectacular, except that the potatoes were slightly lumpy. Instead of feeling good about how well it turned out overall, you get stuck on how imperfect the potatoes were. CBT would help you step back and look at the big picture, and focus on how it was mostly a success.

As you can see from this list, if you were to engage in one or several of these thinking errors regularly, it would certainly feed your depression or anxiety. And, they can lead to problems in your relationships with others. This is why CBT can be so effective, because it effectively helps people change the negative thoughts that are usually automatic. As these thoughts change and more adaptive, healthy thoughts take their place, you will feel much less depressed or anxious.

Other Aspects of CBT

Compared to many types of psychotherapy, CBT is relatively brief and time limited. Although many things can determine the duration of therapy, 16 sessions is the average number for CBT.

CBT also involves collaboration between the client and therapist. They work together to determine the goals of therapy. It is an educational process in that the therapist teaches the client how to challenge and change maladaptive thought processes and reactions and develop more adaptive ones in order to reach his or her goals. It is up to the client to apply what he or she learns in therapy.

Unlike many types of psychotherapy, CBT also involves homework. CBT therapists typically give their clients assignments each week. These may include reading in addition to practicing techniques discussed in therapy each week.

Much research has been done regarding the effectiveness of CBT. It has been shown to be quite effective for the treatment of many different disorders.