Lessons We Can Learn from Cognitive Behavioral Therapy (CBT)

I have been reflecting lately on the importance of using a Cognitive Behavioral Therapy (CBT) approach with my clients in therapy. Many clients who reach out to me specifically request CBT treatment. They have read online that there is a large amount of research demonstrating its effectiveness. Friends have mentioned that this approach helped treat their anxiety or depression. What is it about a CBT approach that makes it so helpful?

1. CBT helps clients believe they CAN change their behaviors:

The most central principle in CBT is that our thoughts and feelings influence our behaviors. Clients often come to therapy to change their behaviors. CBT therapist will help them see the how thoughts and feelings influence behavior, sometimes without their awareness. When we start to pay attention to our daily thoughts we often see we are having more negative thoughts than positive ones. Additionally, doing behavior monitoring as it is called in therapy, can help clients notice their moment-to-moment feelings that can influence their behaviors. Once those patterns are identified, the links can be broken.

Clients Learn to Connect Thoughts and Feelings

For example, we teach clients to pay attention to the negative thoughts that come up during the day like “I can’t believe I botched that meeting so badly today.” Or, “Jen didn’t text me back all weekend, she must be mad at me.”  Therapists teach clients to notice the associated or resulting feelings of sadness, embarrassment, disappointment, and inadequacy. These negative thoughts and feelings make clients more vulnerable to select behaviors that are not helpful to cope. A person might choose to drink the pain away or angrily confront their friend and damage their relationship for the long term. They may even feel that this way of coping is the ONLY way.

Clients Learn to Find Patterns in their Behaviors

But, when we examine common situations like this in therapy, we act like scientists or detectives. Together the therapist and client analyze life events and choose healthy responses that are in one’s best interest. For example, instead of drinking to cover up the feelings of sadness or embarrassment, the person can choose to prepare more for the next work meeting. Or instead of yelling at a friend or ignoring that friend, they reach out to the friend again to remind them of their previous text. Using CBT strategies in therapy can help clients examine their behavior patterns. Then clients can learn to break the links between negative thoughts or feelings and negative behaviors. Thus, CBT helps people feel learn more about themselves and feel empowered to behave differently.

2. CBT therapy helps you THINK better:

In CBT therapy, therapists teach clients skills for how to work with overly negative thoughts. One skill is called cognitive restructuring. Cognitive restructuring involves actively working to reframe the negative thoughts that come automatically into our minds into more realistic or positive thoughts. One way this is done is to examine the cognitive distortions, or negative thought patterns, we all get caught in.

Clients Look at their Negative Thoughts

Therapists use specific types of questioning to help clients figure out where their negative thoughts originated from, and then test them in a scientific way to see if the client can provide evidence for or against each thought. We teach clients that just because a thought comes into one’s head, does not mean it is true. In other words, thoughts are not facts. Although this skill might seem easy, when a person is in the depths of depression, they are not thinking as clearly as they usually do! In fact, their negative thoughts are all linked together, they have more difficulty remembering times in their life that they were happy, and they have a harder time thinking of solutions to their problems. The questioning of the negative thoughts that come into one’s head automatically, can allow the client to choose a more realistic or positive thought to replace it with.

One example of a cognitive distortion is, “Parenting is impossible. I can’t get John to do anything I want him to do! I’ll never get this right!” It is an example of “catastrophizing,” or a belief that because something difficult/bad has happened that you are doomed to the worst case scenario. Today, you could not get your son, John, to pack up his things for school in the morning and now you’ll never be able to help him. And on top of that, you’ll never be a good parent!

Clients Dispute their Negative Thoughts

Stepping back from this situation and disputing its truth in CBT therapy can help a client challenge this belief. The therapist can help the client identify examples of time they were effective as a parent (e.g., helping their child learn to potty train, helping their child learn how to make friends in school). This may help the person acknowledge the difficulty that comes with learning how to be an effective parent while also remembering one’s successes. And then the client can define some behavior they would like to target for new learning. Then the client works on learning specific strategies to help the child pay attention to directions. Developing more realistic and positive thoughts and learning concrete skills for more effective behavior result in a lift to the client’s mood!

3. CBT therapy helps you FEEL better:

I find that clients who reach out to me for help are often carrying their distress in their bodies. This shows up as lower back pain, tightness in the neck and shoulders, sinus pain in the face, and stomach distress. I model how important it is to take time to check in with oneself about whether and where I am holding tension in my own body. We can practice this skill together in session. Some clients report that they have tried this before when doing a body scan meditation practice. This helps clients connect their meditation practice to the work of therapy, which I often think of as understanding our internal sensations better. When we begin to understand patterns in our bodily sensations, we can learn to change our interpretations of what they mean. For example, tension in the neck is attributed to the way one was sitting watching Netflix the night before, rather than being tense about a work meeting. Butterflies in the stomach are interpreted as excitement to demonstrate what you have studied rather than fear of the upcoming test.

Clients Practice Relaxation Techniques

CBT therapists also teach skills to help clients relax their bodies. I work with many clients who have high anxiety and teach them how to do deliberate breathing practices (e.g., square breathing, belly breathing). I also teach progressive muscle relaxation in which clients learn to flex one muscle group at a time and then relax it so they create a feeling of relaxation throughout the body. Clients who practice progressive muscle relaxation at nighttime find themselves drifting off to sleep more easily. They are able to link their feelings of relaxation to a slowing of their racing thoughts. Once their thoughts are slowed down enough, they can find time to evaluate, challenge, and modify them.

I often remind my clients that these strategies do not come easily and that they need to be learned and practiced. It is not that the client is broken and has forgotten how to breathe. Instead, we move so quickly as a society that we forget to take consistent pauses in our day to check in with our anxiety levels and try to do something active to change them. This helps clients to be more gentle with themselves and less critical of themselves about not already knowing the strategies that they are learning in therapy.

4. Clients in CBT create a roadmap to their own recovery: 

One of the strengths of a CBT approach to counseling is that there is a great deal of focus on developing specific, measurable, and observable goals for what they want to accomplish in treatment. These are sometimes called SMART goals (Specific, Measurable, Achievable, Relevant, Time Based) One example of a counseling plan goal is:

-In order to deepen my relationship with my partner, I would like to have 1 conversation with my        romantic partner each week in which I express my feelings and listen actively to my partner’s reactions to what I have said.”

Setting goals in this way allows the therapist and the client to evaluate whether the goal is accomplished each week. It gives the client a structure to practice new behaviors and bring back data to the therapist to examine the strengths of the effort and areas for growth for how to continue deepening the romantic relationship. The therapist keeps track of these goals and checks in with the client on progress at a time interval that makes sense. The goal above is realistic or achievable during 1 week’s time. It is important to be realistic so that the client does not feel so overwhelmed by the assignment that they self-sabotage and fail to accomplish it. The client can debrief in therapy about what this conversation with her partner was like, how she felt, and whether she experienced increased closeness.

Clients Set Achievable Goals

Many goals that clients create are focused on long-term growth such as, “Client will develop a meaningful sense of identity and self-esteem.” This goal could take years to fully accomplish. Therapists can help break these large, meaningful goals into bite sized chunks to make them more manageable. For example, a smaller goal becomes, “Client will state 5-10 personal qualities that she already embodies and 5 qualities that she seeks to develop in the next month.” Identifying more short-term goals helps clients see the progress they are making over weeks and months.  With realistic, bite-sized goals, clients often experience increased hope that their progress is possible. And they can rely on the therapist to hold them accountable for taking important steps towards those goals.

5. CBT therapy includes HOMEWORK that reinforces learning and shortens the length of treatment.

Therapy is typically only a single hour out of a client’s week. In order to get more “bang for one’s buck” in therapy, homework assignments can keep the major take home messages of therapy fresh in a client’s mind throughout the rest of the week. The more my clients practice what they are learning in CBT therapy outside in their regular lives, the more rapidly they observe their symptoms improving. This often means that they obtain new skills more rapidly they can use and are able to complete treatment faster. I try to remind them that this saves them time and money in the long-term.