Imagine a medical treatment based on cutting edge science. I bet what came to mind wasn't doing double dares and playing detective with your diary. But these are just what the doctor orders for treating a range of psychological disorders, like anxiety, depression, OCD, PTSD, insomnia, and more in a type of psychotherapy called cognitive-behavioral therapy (CBT). Today, we take a behind-the-scenes tour of CBT to see how and why it works.
Recently I was reminiscing with a grad school friend about our clinical training. We were sharing our most memorable cognitive-behavioral therapy (CBT) moments. Mine was singing the alphabet song at the top of my lungs with my patient at a busy Boston street corner. Hers was taking a stroll with her patient ... who was walking a banana on a leash.
Yes, you read it right. The patient had a banana on a leash and he was walking it like a dog.
What is cognitive-behavioral therapy?
What do these totally bizarre activities have to do with psychotherapy? How is this supposed to help anyone? Rest assured, both of these patients made huge improvements in tackling their social anxiety. By the end of treatment, they were finally feeling comfortable in their own skin. Of course, bananas and off-key singing weren’t the only ingredients. There’s a lot more to CBT.
CBT is a type of psychotherapy that uses what we know about the brain and human psychology to teach people real-life skills.
CBT is a type of psychotherapy that uses what we know about the brain and human psychology to teach people real-life skills—ones that help us to reduce symptoms of psychological disorders and increase our ability to live fully.
Variations of CBT can be used to successfully treat anxiety disorders, overcome the damaging effects of psychological trauma, alleviate depression for young and old people, reduce the struggle with chronic pain, overcome insomnia, and more.
Today, we take a look behind the scenes to see what CBT is all about. Something this good shouldn't be kept under wraps!
How does cognitive-behavioral therapy work?
Any good psychotherapy starts with a thorough psychological assessment. This can look different from clinic to clinic, but everywhere, the goal is to understand a patient’s symptoms—when did they start, what's happening now, how have the symptoms changed?
Psychological symptoms don’t happen in a vacuum, so it’s important to get to know the whole you.
The therapist should also ask about other aspects of your life. What is your family like? Where do you come from? How do you identify in terms of gender and sexual orientation? Who are the important people in your life? What do you do for a living? What medical conditions do you have?
Psychological symptoms don’t happen in a vacuum, so it’s important to get to know the whole you. For example, let’s say your main concern is that you can’t stop having “bad” thoughts. Your parents’ parenting style, your religion, your health … all of these factors may be important for understanding what’s going on.
Setting goals and identifying values
Assessment doesn’t end after the first meeting. It’s hard to tell a life story in just one hour!
CBT isn’t about a therapist imposing what he or she thinks is right for you; it’s about helping you reach your goals.
A good therapist will keep asking questions to help clarify and update your understanding of your symptoms. But with CBT, we also want to hit the ground running with some concrete changes to your life. Instead of waiting to accumulate all of the answers before taking action, we start right away with some goal-setting and values-identifying.
This step is super important. CBT isn’t about a therapist imposing what he or she thinks is right for you; it’s about helping you reach your goals. So whether it’s improving your mood and motivation, decreasing your fear of flying, coping with trauma nightmares, or becoming more decisive, it’s important for you to name what you want to achieve.
One of my favorite parts of CBT is psychoeducation, which also begins early in treatment.
Psychoeducation is simply a therapist teaching you about psychological science concepts that matter for what you’re struggling with. For patients with anxiety, we talk about how the brain and body respond to fear. For those with insomnia, we talk about how sleep works. For patients with psychological trauma, we talk about how, sometimes, the things we do to protect ourselves backfire and keep our brains and bodies stuck in a chronic trauma response.
But learning about how psychology works is not enough to make real changes in a person’s life. Ultimately, they need to change their behaviors. The mantra that many of my colleagues and I use is, “You may not be able to think your way out of depression, but you can act your way out of it.” That’s because the way we act directly affects how we feel and think. And when the way you feel and think seems out of your control, changing the way you act is your best shot at interrupting a negative cycle and setting you on a positive one.
The way we act directly affects how we feel and think.
For example, one of the best non-medication tools we have to combat depression is behavioral activation, which is exactly what it sounds like—doing more stuff! The tricky thing with depression is that lack of interest or motivation is one of the main symptoms, so someone in the midst of depression probably doesn’t feel like doing much.
This is why we take a fake-it-til-you-make-it approach to scheduling pleasant activities—even if you don’t feel like it, you’re gonna go for a walk anyway! Or call a friend, play the piano, go on a date, bake a cake … whatever gets you moving. Bonus points if the activity is social or gets you outside.
Depending on the specific issues a patient is dealing with, we might get more specific about behavior change. One main thing that many people with anxiety and related disorders struggle with is avoidance. Someone with a fear of dogs might cross the street to avoid a dog. Someone with performance anxiety might turn down an opportunity to play their music to a bigger audience. Someone with intrusive thoughts about contamination might avoid touching door handles.
Avoidance is what keeps anxiety and other disruptive symptoms around.
These avoidances are so understandable. Who wants to be close to the things that bring them fear and dread? And yet, the hard truth is that avoidance is what keeps anxiety and other disruptive symptoms around. It teaches our brains again and again that dogs are dangerous, or that we can’t handle sweaty palms and a pounding heart on stage, or that we have to be completely germ-free to be healthy.
This is where exposure therapy can help.
Remember the banana walking and street corner singing? Those were both social anxiety exposures. The idea is that by doing the opposite of avoiding what you fear, you give the brain and body a chance to learn that it’s probably not as terrifying as you expected. You see that you didn’t die of embarrassment from walking your banana, or that your panic attack was way less noticeable to other people than you had imagined.
The more you practice, the less your body will raise the alarm each time.
Your body also gets a chance to come down from the fight-or-flight alarm on its own time, which teaches it to not get so riled up next time. If you allow yourself to feel the full force of the panic and fear when you get locked in a small room, without fighting it, the anxiety will come down at some point. The next time it happens, your body will produce less of that panic, and the fear will subside more quickly. The more you practice, the less your body will raise the alarm each time, until one day, being in a small room doesn’t even bother you anymore.
This is definitely the least fun part of CBT. I’ve seen more than a few patients cry during exposures, but these brave souls stuck it out and surprised themselves with what they could do.
One eighty-something-year-old patient I had started with feeling distraught even at the thought of being in a closed space. During week three of exposure therapy, his wife locked him in a walk-in closet for a planned two-minute exposure session, then took a phone call, forgot about him, and left him locked in there for 45 minutes! It turned out that he panicked at first, but by about five minutes in, his mind and body calmed down, and by the time his wife went to let him out, he was just calmly twiddling his thumbs.
So far we’ve talked about behavior—the “B” in CBT. What about the “cognitive” part? This refers to working with our thoughts.
Cognitive therapy is not about putting on rose-colored glasses and pretending things are great when they’re not.
Sometimes, people protest that they don’t want to lie to themselves or that “thinking positive” hasn’t worked for them. Don’t worry. Cognitive therapy is not about putting on rose-colored glasses and pretending things are great when they’re not.
Instead, cognitive therapy helps us to become more accurate, balanced, and fair in the way we think. We may not even realize it, but often, we get stuck in unhelpful ways of thinking for so long that they become automatic. So it’s like we’ve put on fear-colored glasses or self-loathing shaped goggles, and everywhere we look, what we see confirms our belief that relationships are dangerous or that we don’t deserve love.
Cognitive restructuring helps us to identify our unhelpful thought patterns, and to start dismantling them, so we can be free to see things as they are--not perfect, but probably more complex and less dire than they seemed before.
It’s like we’ve put on fear-colored glasses or self-loathing shaped goggles, and everywhere we look, we confirm our beliefs.
During this part of CBT, your therapist would probably ask you to keep track of your unhelpful thoughts. During sessions, you would examine these thoughts together, using your curiosity to explore patterns, figure out where they come from, and try on new perspectives. It’s like carving new trails in a forest—the more your brain practices new ways of thinking, the easier it will be to automatically live in a state of having more balanced and helpful thoughts.
Mindfulness and acceptance
We’ve covered the core ingredients of traditional CBT. In the past couple of decades, psychologists and therapists are more and more interested in some other elements. Now, we often incorporate mindfulness—the practice of being in the present moment without judgment—into CBT. This may involve meditation practice, or taking a mindfully accepting stance towards our difficult thoughts and feelings. These approaches can be particularly helpful when we’re dealing with situations or symptoms that aren’t so easy to control, like chronic illness or unavoidable stress.
Interpersonal effectiveness and emotion regulation
Another well-known development of CBT is Dialectical Behavior Therapy (DBT), which is designed for people who struggle with volatile emotions, self-esteem issues, and chronic relationship drama. This therapy teaches skills for regulation emotions, even during crises. It also teaches ways to be interpersonally effective, like how to be assertive and how to not push people away during difficult conversations. I’m a big fan of DBT!
Is CBT (or ACT, DBT) right for you?
There are some psychologists who will tell you strongly that CBT is the only way to go because it’s the most evidence-based type of psychological treatment. This is not wrong! I myself was trained at the mecca of CBT, the Center for Anxiety and Related Disorders at Boston University. The world-class CBT training here showed me that it really does work to alleviate phobias, panic disorder, social anxiety, OCD, PTSD, and other related psychological disorders.
You’ll likely come out the other side with a literally rewired brain, and more importantly, a set of lifelong tools for mental health.
If your main goal is to finally take your life back from OCD, or knock the social anxiety down enough that you can give a Best Man toast at your brother’s upcoming wedding, or figure out how not to struggle with sleeplessness night after night ... CBT is your best shot. Expect to dedicate between a few weeks to a few months of your life to psychology boot camp. If you put in the work, you’ll likely come out the other side with a literally rewired brain, and more importantly, a set of lifelong tools for mental health.
But psychological disorders are messy. Not everyone’s symptoms can be totally cured by CBT. Some do need medications or another type of treatment. Also, people are messy. Not everyone has a well-defined psychological disorder, or if they do, their life may be much more complicated than simply having this disorder.
Sometimes there’s grief in the mix, or an actively toxic relationship, or financial hardship, spiritual indecision, physical illness, immigration status uncertainty, or sometimes, a general feeling that even though they have a clean bill of psychological health and a perfect life on paper, life just isn’t fulfilling.
The right combination of ingredients depends on your unique needs.
This is where some elements of good old fashioned insight-oriented therapy, supportive therapy, or combination approaches could help. The good news is that therapy, in the real world, is rarely black-and-white. For example, a therapist might start by encouraging you to go for a walk every day, just to give you a mood boost. Then, they may want to know more about your childhood experiences to gain insight into possible defense mechanisms. At the same time, they may also gently challenge you to go outside your comfort zone by standing up to your bullying coworker. Here, we’ve got behavioral activation, psychoanalysis, assertiveness training, and a little bit of exposure therapy.
The right combination of ingredients depends on your unique needs. So, sometimes, the question is more about how to find a good therapist, one that has the expertise to address your concerns and a style that meshes well with your personality.
In next week’s episode, we will talk about how to find a therapist and how to know whether you’ve found a good match. We’ll get nitty-gritty about all the details—where to look, what questions to ask, and even how much you can expect to spend. Stay tuned!