Cognitive Behavioral Therapy (CBT) – the Most Effective Therapy?
Image: Counseling by Tiyo Prasetyo (CC0)
Synopsis: CBT is one of the most effective forms of psychotherapy demonstrated in research. It is a time-limited therapy that is focused on skills-building. This article outlines basic CBT principles, explains how it works and includes an example thought log. Read more to figure out if CBT is the right fit for you.
BY LEN LANTZ, MD / 1.10.2020; No. 10 / 6 min read
Disclaimer: Yes, I am a physician, but I’m not your doctor, and this article does not create a doctor-patient relationship. This article is for educational purposes and should not be seen as medical advice. You should consult with your physician before you rely on this information. This post might also contain affiliate links. Please click this LINK for the full disclaimer.
What does CBT promise and where did it come from?
When you have a strong emotional reaction that is out of proportion to the situation, your first and most important step is to stop and think. An extreme emotion usually is a signal from your brain telling you to put everything on hold so that you can put things into perspective.
Dr. Albert Ellis was the first researcher who really looked at cause-and-effect from thoughts to emotions in his therapeutic approach called Rational Emotive Behavioral Therapy (REBT). You can read about this approach in his book A Guide to Rational Living by Drs. Ellis and Harper if you want to learn more about where Cognitive Therapy (CT) and Cognitive Behavioral Therapy (CBT) actually began and how to apply them in your life. He demonstrated the concept that prior to experiencing emotions, people typically have a preceding or triggering thought. If a person’s emotional reactions are greatly out of proportion to a given situation, it is likely that their thoughts were first unbalanced.
Now, I think it’s important to point out that not every person has a negative thought before they have a negative emotion. For example, mood disorders, such as bipolar disorder or major depression, sometimes bring about strong emotions whether or not triggering thoughts are present. However, negative thoughts can still escalate these emotions, and learning to replace negative thoughts with more balanced thoughts can be very helpful.
Does CBT fit your needs?
If you are considering psychotherapy, you need to find out if cognitive behavioral therapy would meet your needs. Cognitive behavioral therapy is:
Time-limited
An approach where the therapist is more like a coach than just a sympathetic, well-meaning listener
Oriented around gaining insight about yourself and your mental habits/reactions, but not really about understanding or going far back in your past
A lot of work between therapy sessions
Focused on skills building
For people who want to work very hard in a time-limited manner in therapy
For people who want therapy that has the strongest evidence base in the research literature and who want to gain lasting skills to deal with negative emotions, negative thoughts and negative life events
Pitfalls in CBT
The most common error that I have seen in CBT is that patients are not assigned homework/skills to practice between therapy sessions. Another problem is when people are not working through a specific learning curriculum with their therapist. A third pitfall is when the beginning, middle and end of therapy are not defined in advance. The heart of CBT involves people working through thought logs, which are foundational to thought balancing and cognitive reframing.
Thoughts vs. Emotions
Let’s take a minute to talk a little bit about the difference between thoughts and emotions, because the two are often confused and the distinction is very important in CBT. Thoughts can be very automatic and may occur without your awareness. Different people could have different thoughts about the same event, and these thoughts could result in a variety of emotions. No wonder people get confused about this!
Examples of thoughts (what we say to ourselves):
I’ll never get to sleep!
That’s awful!
I’m stupid
He’s a jerk
I want to cry
Nobody loves me
Examples of emotions (how we feel):
Sadness
Anger
Worry
Fear
Jealousy
Joy
Calmness
Coping with anxiety in CBT
Anxiety coping skills can help you tackle some of the more challenging work in therapy without the therapy itself stressing you out too much. It’s important to learn how to use the skills and practice them regularly as you move through therapy. Here are some of the most effective anxiety coping skills:
Deep Breathing – focusing on slow, intentional “belly” breathing
Progressive Muscle Relaxation – a methodical approach to paying attention to muscle tension and relaxing each part of the body
Autogenic relaxation – a methodical approach to visualizing different body parts becoming warm and heavy, resulting in relaxation
Mindfulness Exercises – bringing your attention to a specific area of focus for a defined period of time, understanding that at some point you will get distracted and practicing accepting this as you bring your awareness back to the chose focus area (my favorite mindfulness exercise is the M & M technique).
Automatic thoughts
The thought log is the heart of cognitive behavioral therapy. It involves mapping out situations, thoughts and emotions and finding ways of replacing unbalanced thoughts that inappropriately trigger or escalate powerful negative emotional responses. These unbalanced thoughts are sometimes referred to as automatic thoughts because they can occur instantaneously.
Automatic negative thoughts often lead to powerful negative emotional responses. Imagine someone experiencing a litany of negative thoughts all day, every day. That person would probably feel like an emotional wreck. Thought logs help people to identify their automatic thoughts and find more balanced alternative thoughts. By practicing these thought-balancing exercises on paper enough times, they learn to do thought balancing in the moment. By learning to identify their most common unbalanced thoughts, rather than reacting to those thoughts, they could say to themselves “Oh, there’s that thought again!” and let it go.
The thought log and cognitive reframing
Here is a situation from my life that we can use as an example to work through the thought log: I was driving to work in dense traffic and a guy in a muddy, jacked-up pickup in the lane next to me swerved into my lane right in front of me. I had to hit my brakes and swerve, and I honked my car horn. The dude just kept driving…really speeding down the road! I felt really angry, and my anger lingered, ruining my entire morning.
This is how a thought log works using the example above with numbered columns below:
Wait to complete a thought log until you’ve calmed down and can process the situation.
Write down the date and time the event occurred.
Describe the situation. Where were you, who were you with, what happened earlier that day?
What emotions were you feeling? Pick the most powerful one.
What was your automatic thought or what were your automatic thoughts? Pick the most powerful thought.
What data supports your most powerful automatic thought?
What data does not support your most powerful automatic thought?
What is your new balanced thought based on the data?
Based on your new balanced thought, how do you feel?
Image: Sample Thought Log by Len Lantz (CC BY-NC-ND)
Click HERE for a downloadable pdf of the above CBT Thought Log.
You can see how completing the above thought log reduced the intensity of my negative emotion. By the way, my favorite cognitive behavioral therapy workbook is Mind Over Mood by Drs. Dennis Greenberger and Christine Padesky. They have one of the best thought logs I have ever seen.
If you hate workbooks or mental health books but want to learn more about how to do cognitive reframing (which is what happens in a thought log), check out my favorite leadership book, Leadership and Self-Deception, by The Arbinger Institute, as it has a ton of CBT principles infused into its approach.
Core Beliefs
One of the ultimate goals in doing a thought log is to positively influence core beliefs. Core beliefs are very closely held beliefs that people have about themselves, others and the world. These core beliefs can lead to negative, unbalanced automatic thoughts. By replacing unbalanced thoughts on a regular enough basis using a thought log, core beliefs will eventually be positively impacted. Think about it. All of us have some problems with some of our most closely held beliefs. What if your core belief was that you could only trust yourself? Imagine how that would impact your relationships and result in feelings of loneliness. What if your core belief about the world was that it is a dangerous place? Your resulting fear could cause you to avoid meaningful activities and keep you from thriving.
Why choose CBT?
The benefit of choosing to do cognitive behavioral therapy is that it is probably one of the most effective forms of psychotherapy. Because it is time-limited, it is also probably one of the best uses of your time and resources if you are struggling in managing your thoughts and emotions. Imagine being able to balance out your thoughts in the moment because you’ve practiced it enough on your own and with a therapist. Consider being able to cope better with stressful situations, using coping skills to get through a panic attack, effectively shutting down self-hating thoughts, and even changing core beliefs that currently lead you into self-destructive or self-defeating behavior. Wouldn’t that be great? Only you and your doctor or therapist will be able to determine if cognitive behavioral therapy is right for you, but if you find an excellent therapist who is skilled in CBT, chances are you will be glad you invested your time and effort.
For further reading, check out:
My article “Finding Quality Psychotherapy – Moving Beyond Talk Therapy“
My article “Finding a Good Psychiatrist“
A Guide to Rational Living by Drs. Ellis and Harper (See Len’s Book Review)
Mind Over Mood, Second Edition: Change How You Feel by Changing the Way You Think by Drs. Dennis, Greenberger and Padesky (See Len’s Book Review)
The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients by Dr. Yalom (See Len’s Book Review)
Leadership and Self-Deception: Getting Out of the Box by the Arbinger Institute (See Len’s Book Review)
