You’ve obviously heard about cognitive therapy (CT), also known as cognitive behavior therapy (CBT), and perhaps you practice it. But most psychotherapists in the U.S. do not identify themselves as CBT therapists, instead practicing an eclectic brand of therapy combining psychodynamic theory, supportive techniques, basic problem solving, and a smattering of other therapeutic tools. This article is a quick refresher course on what CBT is, and how a CBT therapist approaches patients.
The Cornerstone: Automatic Thoughts
People often have automatic thoughts, below their level of awareness, about aspects of their lives. Regardless of whether these beliefs are supported by evidence, they can influence mood. Cognitive behavioral therapists help clients identify these automatic thoughts, and, especially if they are negative, question them. For example, one of my clients constantly worried that her boyfriend was no longer interested in her. We examined her conviction in therapy, and I encouraged her to ask herself questions, such as:
- How does this thought affect my mood and behavior?
- If a friend had this belief, what would I tell her?
- What evidence supports, or fails to support, this idea?
Such scrutiny allowed the client to discover that, by her own assessment, her concern appeared unfounded. This reduced her anxiety, and allowed her to decrease her frequent checkup calls.
For a videotaped example of modifying automatic thoughts using CBT, see http://bit.ly/t7EiYH.
There are connections between our thoughts, our emotions, and our behaviors. While this may seem obvious, patients can be oblivious to these connections, preventing them from making real changes in their lives. For example, a client felt despondent but did not realize that this emotion was triggered by an acquaintance’s failure to greet him. I said, “Try to remember what you were thinking when your mood changed to sadness.”
“I assumed my friend was ignoring me because she doesn’t like me any more.” I encouraged him to come up with some possible alternative explanations: perhaps the acquaintance did not see him, or was in a rush, or feared he might interpret a greeting as flirtatious. If you ask clients to estimate the likelihood of these alternatives, they will likely see that their feelings are due to an unjustified perception of rejection, and their moods will improve.
The connections between thoughts and behavior can be surprising. For example, sometimes people infer their mood from their behavior, like the speaker giving a presentation on a lower deck in a cruise ship, who assumed, because his legs were shaking slightly, that he was nervous—until he realized the floor was vibrating because it was close to the propeller shafts.
Controlled experiments have shown that people infer their feelings from behavior, or what they think is their behavior. In one classic study, men looked at nudes in Playboy as they listened to what they thought were their own heart rates, but was actually a tape of heart rates from others. The men were then asked to rate their attraction to the nudes. Experimenters found men gave the highest ratings to the nudes they saw when they thought their heart was beating faster or slower than normal, even though this “feedback” about their heart rate had nothing to do with their actual heart rate. In short, the men inferred their feelings of attraction based on their beliefs about the behavior of their heart, just as the speaker on the cruise ship inferred his feelings of stage fright based on the behavior of his trembling legs (Valins S, J Pers Soc Psychol 1966;4(4):400–408).
Correcting Thinking Errors
Thinking errors, or distorted thinking, can affect mood. For example, many clients overgeneralize from a single failure—a bad score on a test, a date who didn’t show up—and conclude they are failures. Sometimes they extend that form of distorted thinking with catastrophizing, where one negative incident mushrooms into an imagined chain of events ending in disaster. For example, a client discovered that she was in the habit of imagining that a minor mistake would turn into a sequence of problems which would cause her to lose her job and income source, and imagined she would be forced to give up custody of her son. When I asked her to estimate the likelihood of each link in her scenario, she saw how improbable her nightmare was.
Other common distortions include black-and-white thinking; focusing on the negative; and mind-reading.
- Black-and-white thinking, also known as polarized, or all-or-nothing, thinking, is imagining that events will become one extreme or its opposite. For example, a client may feel that if he is not a complete success, he is a total failure, or that if people at a party are not as welcoming as he’d like, they are all unfriendly.
- Focusing on the negative involves filtering out the positive details of experiences. A client may notice only that the buttons are not spaced perfectly in the beautiful hand-knit sweater from her daughter. She perceives only her prospective partner’s minor flaws, rather than the more numerous, and more significant, strengths. Such distortions rob clients of joys they might otherwise feel, and may weaken their relationships because they find little to appreciate.
- Mind reading involves a client guessing what others are thinking and feeling, and believing he is correct without sufficient evidence. He may assume his classmates don’t like him, so he avoids looking at them or joining them after class. Or he is convinced, without reason, that his coworkers think he is not as smart as they are, so he stops contributing to discussions, lest he confirm their beliefs.
Behavioral activation is a technique that is particularly helpful for depressed and poorly motivated clients. The technique was satirized in the movie “What About Bob,” in which the psychiatrist urges his patient, played by Bill Murray, to take “baby steps.” Comedic or not, the technique works, and it involves discussing with clients in extreme detail what they need to do to accomplish goals, whether it is a job assignment, or preparing the house for the holidays. The trick is to break down the challenge into manageable steps. This approach is effective because, despite the withdrawal and passivity characteristic of depression, clients can often accomplish their customary tasks if someone helps them start. The key is to begin with something small, rather than ambitious.
The therapist and client can jointly schedule the client’s day, including even minor items, such as, “fix breakfast” and “take the train to work.” As psychologist and CBT researcher Steven Hollon, PhD, puts it, when you’re depressed, “you always have two things to do: you have to decide what to do, and you have to do it. If we can help a depressed patient decide in advance, all he has to do is carry it out” (The Carlat Psychiatry Report 2010;8(7&8):8).
You can sometimes help your clients disconfirm irrational thoughts by asking them to test their beliefs. Clients may be reluctant to take small risks that would probably be in their best interests, such as applying for a job, because they fear rejection or failure. Ask your client to estimate the odds of success, and to imagine the actual consequences of failure. This approach helps them see that success is more likely than imagined, and that failure would not be as painful as predicted.
For example, a very social client had a new boyfriend, and was excited about the relationship. To ensure that she would be available in case he called her to go out, she began to avoid going out with her many friends. She developed the belief that she could not check with her boyfriend before going out, because he might feel she was trying to manipulate him into a date. Consequently, for months she reserved every night and weekend for her boyfriend, and often stayed home alone—until, with some trepidation, she tried a behavioral experiment: going out with her friends. The results did not support her belief that her boyfriend would get upset with her if she were unavailable, so she was eventually able to think more realistically about her social life, and resume going out with her friends.
CBT therapists are famous for assigning homework. Often, this involves automatic thought records. One such record is a diary with columns for recording specific features of distressing events in the day, such as the time, situation, and the client’s negative emotions. Columns are often included for clients to record the automatic thoughts they had while in the situation, and rate how accurate they believe those thoughts are. Finally, at bedtime, clients again rate the accuracy of the automatic thoughts they have listed throughout the day, generally noticing patterns of distortion. For example, clients typically feel that while they are having a problem, such as being stuck in traffic on the way to work, it is very likely that they will be late, and their boss will be angry with them. By the time they rate the likelihood of these problems at the end of the day, however, the outcomes they feared in their automatic thoughts seem far less likely. This persistent gap forces clients to see that they are overreacting to stressors. In addition, thought diaries can show which particular kinds of distorted thinking (overgeneralization, catastrophizing, and so on) a given client tends to use. For a sample thought record sheet, see www. get.gg/docs/ThoughtRecordSheet7.pdf