Introduction to Cognitive Behavioral Therapy
By Nelson Binggeli, PhD
The principles and methods of Cognitive Behavioral Therapy (CBT)
are among the primary ways that I help my clients achieve their
goals for positive change in their lives. Because CBT is a very
collaborative form of therapy, I believe it is helpful for my
clients to understand these principles and methods. Ultimately, I
would like for my clients to become skilled in using CBT on their
own to meet the challenges in their lives, long after their work
with me has ended. Prior to reading this material, please read
mydisclaimerregarding information provided on this website.
An overview of CBT
CBT is a form of psychotherapy that has been demonstrated to be
effective in helping to people to overcome a wide variety of
problems, including those involving depression and anxiety. It is
based upon scientifically-informed principles of human psychology
and its effectiveness for many problems has been supported by
hundreds of scientific studies. CBT focuses on the patterns of
thought and behavior that maintain both adaptive and maladaptive
behavior. It assumes that these patterns are learned, and that new
patterns can be learned when old ones are no longer useful.
CBT tends to be a present-centered, active, collaborative, and
short-term form of therapy. Although therapists do not disregard
how problems may have developed (e.g., as a result of childhood
experiences), their primary focus is on helping the client identify
and change what is maintaining the problem in the present. The
relationship between the therapist and the client is marked by
collaboration, and clients are encouraged to take an active role in
applying the techniques both within and between therapy sessions.
Therapy tends to be short-term (often between 5-30 sessions over a
period of one to 18 months), and emphasizes the client learning
principles and techniques that will serve them long after their
work with the therapist has ended.
Cognitive aspects of CBT
Cognition can be defined as the mental processes of perceiving,
remembering, reasoning, evaluating, and imagining. CBT holds that
most of our emotions and behaviors are the result of our cognitions
regarding what we think or believe about ourselves, other people,
and the world. These cognitions shape how we interpret and evaluate
what happens to us, influence how we feel about it, and provide a
guide to how we should respond. Unfortunately, sometimes our
interpretations, evaluations, and underlying beliefs thoughts
contain distortions, errors, or biases, or are not very useful or
helpful. This results in unnecessary suffering and often causes us
to react in ways that are maladaptive. CBT provides many methods
for becoming more aware of our cognitions and for modifying them
when they are distorted or are not useful. Collectively, these
methods are called cognitive restructuring.
Behavioral aspects of CBT
The behavioral aspects of CBT emphasize the role of what we do
(i.e., our behavior) in shaping how we feel, what we believe, and
how we behave in the future. In CBT, the therapist helps the client
to identify which behaviors are likely maintaining the problem, and
which behaviors are likely to help produce positive changes. Often,
problems are the maintained by avoidance, either of actual
situations or of internal experiences (such as emotions and
memories). This prevents new learning that potentially could
disprove distorted negative beliefs about oneself, others, and the
world, and keeps people stuck in old maladaptive patterns. It also
prevents people from experiencing positive reinforcement that
provides satisfaction and motivation. In CBT, the therapist and
client collaborate in choosing new behaviors for the client to
engage in that help the client to gradually overcome this
avoidance.
The behavioral aspects of CBT are guided by scientifically-based
principles of learning derived from over a century of research on
animal and human behavior (such
asclassicalandoperantconditioning).
Techniques of CBT
The following are some of the primary techniques used in CBT.
More information about each technique can be found by clicking on
the name of the technique.
(1)Promoting more accurate and useful thinking (cognitive
restructuring): A key component of CBT is called cognitive
restructuring, which is a set of procedures that promote more
accurate and useful thinking. It is very helpful in treating
depression, anxiety, and other problems.
(2)Increasing rewarding activity (behavioral activation):
Depression often leads to withdrawal, avoidance, and inactivity.
This prevents people from having positive experiences that are
satisfying and motivating. Through a set of techniques called
behavioral activation, CBT helps people to identify and engage in
activities that increase the chance they will have rewarding
experiences.
(3)Overcoming anxiety by facing fears (exposure therapy):
Anxiety disorders are maintained by avoidance. CBT helps people
overcome anxiety by facing their fears in a systematic way called
exposure therapy.
(4) Learning new skills (skills training): Sometimes people
avoid certain situations because they perceive they lack the skills
to manage them. Accordingly, CBT also often includes learning new
behavioral skills, such asassertive communication skillsto deal
with social situations andrelaxation skillsto deal with
anxiety.
A very brief history of CBT
CBT is actually a merger of many different theories and streams
of research. The cognitive aspects have their roots partly in the
work of psychoanalysts who broke with Sigmund Freud, such asAlfred
Adler, and partly in theStoic philosophersof ancient Greece who
were introduced to psychology byAlbert Ellis. Ellis may be
considered the first psychologist that produced a fully-formed
version of cognitive therapy beginning in the 1950s (now
calledRational Emotive Behavioral Therapy).Aaron Beckalso developed
somewhat similar form of cognitive therapy beginning in the 1960s.
Becks version forms the basis of the most widely researched and
practiced form of cognitive therapy today (and is the form that I
practice). The behavioral aspects of CBT have their roots in
thebehavioristtradition of psychology, particularly influenced by
the research ofIvan PavlovandJohn B. Watsonearly in the 20th
century andB. F. Skinnerin the mid-20th century. An important early
behavioral therapist wasJoseph Wolpe. An important theorist and
researcher who helped to bridge the gap between the cognitive and
the behavioral isAlbert Bandura. There are many more important
theorists and researchers that this brief history necessarily
omits.
For further reading
More information about CBT can be found on the websites of the
following professional organizations:
Academy of Cognitive Therapy
Association for Behavioral & Cognitive Therapies
Beck Institute for Cognitive Therapy & Research
National Association of Cognitive Behavioral Therapists
An article describing CBTby Ben Martin, PsyD on
PsychCentral.com
Research supporting CBT
Butler AC, Chapman JE, Forman EM, & Beck AT. (2006).The
empirical status of cognitive-behavioral therapy: a review of
meta-analyses.Clinical Psychology Review, 26, 1, 17-31.
Hollon, S. D., Stewart, M. O., & Strunk, D. (2006).Enduring
effects for cognitive
behavior therapy in the treatment of depression and
anxiety.Annual Review ofPsychology, 57, 285315.
Olatunji BO, Cisler JM, Deacon BJ. (2010).Efficacy of cognitive
behavioral therapy for anxiety disorders: a review of meta-analytic
findings.Psychiatric Clinics of North America, 33, 3, 557-77.
The Society of Clinical Psychology (a division of the American
Psychological Association) provides a summary ofResearch Supported
Psychological Treatments, many of which are based on CBT.--Last
updated: 02.05.10--Navigation:Home>Resources>Coping skills
& treatments> Cognitive Behavioral TherapyCBT techniques,
part 1: Cognitive restructuring
By Nelson Binggeli, PhD
Introduction
This is the first in a series of three articles describing the
primary techniques of Cognitive Behavioral Therapy (CBT). Prior to
reading this article, please read myIntroduction to CBTand
mydisclaimerregarding information provided on this website.
This article focuses on a set of techniques called cognitive
restructuring, which help to to promote more accurate and useful
thinking. It is very helpful in treating depression, anxiety, and
other problems.
An overview of cognitive restructuring
CBT holds that most of our emotions and behaviors are the result
of what we think or believe about ourselves, other people, and the
world. These cognitions shape how we interpret and evaluate what
happens to us, influence how we feel about it, and provide a guide
to how we should respond. Unfortunately, sometimes our
interpretations, evaluations, and underlying beliefs thoughts
contain distortions, errors, or biases, or are not very useful or
helpful. This results in unnecessary suffering and often causes us
to react in ways that are not in our best interest.
Cognitive restructuring is a set of techniques for becoming more
aware of our thoughts and for modifying them when they are
distorted or are not useful. This approach does not involve
distorting reality in a positive direction or attempting to believe
the unbelievable. Rather, it uses reason and evidence to replace
distorted thought patterns with more accurate, believable, and
functional ones.
An illustration
To illustrate the role of thoughts in influencing emotions and
behavior, consider the following vignette1: Suppose you are at a
party and have been introduced to Alex (you can imagine Alex as a
male or as a female). As you talk, Alex never looks at you; in
fact, throughout your brief conversation s/he looks over your
shoulder across the room. What are you thinking and feeling, and
how would you respond?
This is deliberately an ambiguous situation that can be
interpreted in many ways, because much of life is like this. We
often have to make sense of what is happening to us based upon
limited information. Lets consider how three different people
interpreted and reacted to this scenario:
Person A thought Alex is rude. S/he is insulting me by ignoring
me. As a result, they felt annoyed and they terminated the
conversation and avoided Alex at future parties. Person B thought
Alex doesnt find me interesting. I bore everybody. As a result,
they felt ashamed and depressed, and they left the party and became
more likely to decline invitations to parties in the future. Person
C thought Alex seems shy. S/hes probably to uncomfortable to look
at me. As a result, they felt sympathetic and attempted to engage
Alex in a conversation about how Alex knew the host of the
party.
This vignette illustrates that given the same situation, people
can have very different interpretations and reactions. Often these
are indicative of recurrent patterns of thought and underlying
beliefs. CBT holds that when we are experiencing problems in our
lives, it can be very helpful to become aware of these patterns and
beliefs and to be curious about how accurate and useful they
are.
The cognitive (ABC) model
Albert Ellis, one of the pioneers of CBT, illustrated how our
emotions and behaviors are often the result of what we think or
believe with his ABC model. In the model, A stands for the event or
situation that triggers a cognitive, emotional, and behavioral
reaction. B stands for our underlying beliefs about ourselves,
other people, and the world and the resulting interpretations and
evaluations we make of the event or situation. C stands for the
consequence of our interpretations and evaluations which can
include both an emotional reaction and a behavioral response. To
show how the model works, I have used the experience of Person B
from the vignette above.
Cognitive distortions
The term cognitive distortion refers to errors in thinking or
patterns of thought that are biased in some way. They may include:
(A) interpretations that are not very accurate and which
selectively filter the available evidence, (B) evaluations that are
harsh and unfair, and/or (C) expectations for oneself and for
others that are rigid and unreasonable. The more a persons thinking
is characterized by these distortions, the more they are likely to
experience disturbing emotions and to engage in maladaptive
behavior. A number of common patterns2of cognitive distortions have
been identified, including:
1. All-or-nothing thinking: Looking at things in absolute,
black-and-white categories, instead of on a continuum. For example,
if something is less than perfect, one sees it as a total
failure.
2. Overgeneralization: Viewing a negative event as a part of a
never-ending pattern of negativity while ignoring evidence to the
contrary. You can often tell if youre overgeneralizing if you use
words such as never, always, all, every, none, no one, nobody, or
everyone.
3. Mental filter: Focusing on a single negative detail and
dwelling it on it exclusively until ones vision of reality becomes
darkened.
4. Magnification or minimization (e.g., magnifying the negative
and minimizing the positive): Exaggerating the importance of ones
problems and shortcomings. A form of this is called catastrophizing
in which one tells oneself that an undesirable situation is
unbearable, when it is really just uncomfortable or
inconvenient.
5. Discounting the positive: Telling oneself that ones positive
experiences, deeds, or personal qualities dont count in order to
maintain a negative belief about oneself. Or doing this to someone
else.
6. Mind reading: Concluding what someone is thinking without any
evidence, not considering other possibilities, and making no effort
to check it out.
7. Fortune telling: Anticipating that things will turn out
badly, and feeling convinced that the prediction is an already
established fact. It often involves: (A) overestimating the
probability of danger, (B) exaggerating the severity of the
consequences should the feared event occur, and (C) underestimating
ones ability to cope should the event occur. B and C are also
examples of catastrophizing.
8. Emotional reasoning: Assuming that ones negative emotions
necessarily reflect the way things really are (e.g., Because I feel
it, it must be true. I feel stupid, therefore I am stupid).
9. Rigid rules (perfectionism). Having a precise, fixed idea of
how oneself or others should behave, and overestimating how bad it
is when these expectations are not met. Often phrased as "should"
or must statements.
10. Unfair judgments: Holding oneself personally responsible for
events that aren't (or arent entirely) under ones control, or
blaming other people and overlooking ways in which one might have
also contributed to the problem.
11. Name-calling: Putting an extremely negative and
emotionally-loaded label on oneself or others. It is an extreme
form of magnification and minimization, and also represents a gross
overgeneralization.
In addition to the above list which is largely influenced
byAaron Becksversion of cognitive therapy,Albert Ellisproduced a
similar list that highlights what he calledirrational beliefs(which
consist of faulty assumptions and unreasonable rules about
life).
The origin and function of cognitive distortions
Where do these distortions come from, and what purpose do they
serve? Frequently, cognitive distortions develop in childhood as
the result of unfortunate and difficult life experiences and/or
being taught to use them by significant others (e.g., parents and
peers). We also become more prone to cognitive distortions when
under stress, because under pressure we are apt to take more
cognitive shortcuts resulting in less accurate and more extreme
interpretations and reactions. Cognitive distortions can also serve
the function of trying to protect us from harm. For example, when a
depressed or anxious person thinks, I cant do it, it justifies
inaction and protects the person from possible failure. Of course,
this strategy is ultimately self-limiting and defeating, and keeps
people stuck in old patterns that dont work very well.
How CBT views emotions
CBT is not saying that all negative or painful emotions are bad
and that we should always think positively. Emotions such as fear,
anger, and sadness can be very appropriate and even useful. Fear
can tell us there is danger, and motivate us to protect ourselves.
Anger can inform us that our rights are being violated, and we need
to take action to assert our rights. Sadness can be the result of
losing something or someone important to us, and can indicate that
we need to take the time to grieve.
What is important is not whether an emotion is positive or
negative, but whether it is adaptive or maladaptive. Negative and
painful emotions can be adaptive if they are based on accurate
thinking and guide an appropriate response. Maladaptive emotions
are driven by distorted thinking and cause unnecessary suffering
and inappropriate responses. One way of defining mental health
might be the extent to which one can recognize the difference
between adaptive or maladaptive emotions.
The process of cognitive restructuring
Cognitive restructuring refers to the process of replacing
cognitive distortions with thoughts that are more accurate and
useful. Cognitive restructuring has two basic steps: (1)
Identifying the thoughts or beliefs that are influencing the
disturbing emotion; (2) Evaluating them for their accuracy and
usefulness using logic and evidence, and if warranted, modifying or
replacing the thoughts with ones that are more accurate and
useful.
In CBT, the therapist guides the client through the process of
becoming more aware of what they are telling themselves and helps
them to evaluate, and when appropriate, to modify their own
thinking. In essence, the therapist teaches the client a process
that will help them distinguish distorted thinking from more
accurate and useful thinking. CBT emphasizes that this is best done
as a collaborative process in which the client is assisted in
taking the lead as much as possible. The therapist refrains from
assuming that the clients thoughts are distorted and instead
attempts to guide the client with questions that encourage the
client to make their own discoveries. Clients are also encouraged
to engage in his process on their own during their time between
sessions by using a written format, described below.
The Cognitive Restructuring Worksheet
When learning Cognitive Restructuring, it is very helpful to use
a worksheet designed to guide the process. I encourage you to
download theCognitive Restructuring Worksheet(which is in Microsoft
Word format) to have available as you read the next section. Having
it in this format allows you to print multiple copies, or to type
directly onto it. The table below depicts the main headings of the
worksheet.
The following are instructions regarding how to use this
worksheet. Below these instructions is an example of a completed
Cognitive Restructuring Worksheet.
Part I: Identifying emotion-causing thoughts
Instructions: When you are experiencing a negative emotion use
the following procedures to identify the emotion-causing
thoughts.
1.Situation: Briefly describe the situation that led to the
emotions.
2. Emotions / ratings: Identify the emotions you are
experiencing and any physical sensations. Emotions can be described
by single words, such as sad, nervous, afraid, angry, guilty, or
ashamed. For more examples of emotion words,click here. Then, rate
the intensity of your emotions using the scale below.
3. Automatic thoughts / ratings: Identify the thoughts or images
connected to the emotions and record them in brief simple
declarative sentences or statements. For examples, see the
completed worksheet below. (These thoughts are called automatic
because they tend to occur automatically or habitually).
Questions3that may help you to identify thoughts are:
1. What is going through my mind as I am feeling this emotion?2.
What am I telling myself about this situation?3. What am I afraid
might happen?
Once you identify a thought, you can further explore the meaning
of the thought to you and record these thoughts. Questions that may
be helpful are:
1. If this thought is true, what does this say about me as a
person?2. What does it say about my life, and my future?3. What is
the worst thing that could happen if it is true?4. What does this
mean about how other people think about me?5. What does this mean
about how I think of other people?6. What images or memories do I
have in this situation?
Once you have identified a number of thoughts, put a star by one
or two of the thoughts that seem to be producing the most emotion
(hot thoughts). Then, rate your degree of belief that each hot
thought is true (0-100%).
Part II: Evaluating and modifying thoughts
The second part of cognitive restructuring involves evaluating
your automatic thoughts and perhaps developing a new perspective
that is more accurate and useful.
Instructions: Choose one or more hot thoughts to work on. It is
best to focus on only one or two of these thoughts at a time.
1. Identify any cognitive distortions: Identify if the thought
contains any cognitive distortions (refer to the list of common
cognitive distortions).
2. Evaluate and modify: Evaluate the accuracy and usefulness of
the thoughts, and if warranted, modify the thoughts in a more
accurate and useful direction.
Some questions3can help you evaluate theaccuracyof a
thought:
1. What is the evidence that supports or contradicts this
thought?2. Is there an alternative explanation? Is there another
way of looking at it?3. Am I overestimating the probability of the
negative event occurring? What is the worst that could happen? What
is most realistic?4. Am I overestimating the severity of the
consequences of the event (should it occur)? Is it really a
terrible catastrophe if X happens? Could I cope with it?5. Does X
have to = Y (e.g., Does not having a dating partner = being a
loser?)6. If a friend had this thought, what would I tell them?
Some questions can help you evaluate theusefulnessof a
thought:
1. What are the advantages of telling myself this? And what are
the disadvantages?2. What might be a more useful or helpful way of
thinking about this?3. To the degree that this belief is true, what
should I do about it?4. 5. Be sure to record any data that
contradicts the thought, and the more rational thoughts you may
have composed.
3. Summarize your new perspective: Summarize or highlight the
key points you discovered as a result of the work you have
done.
4. Go back and re-rate your degree of belief in the hot thoughts
and the intensity of your original emotions. Note whether there has
been a change in your emotions.
Example of a completed Cognitive Restructuring Worksheet
The following is an example of a worksheet completed by a
semi-fictional 20 year-old male college student.4 He has come to
counseling to get help with his depression, low self-esteem, and
social anxiety (e.g., fear of being judged negatively by others).
In particular, he is unhappy because he has never had a girlfriend.
This is largely because he has never initiated relationships with
females because he sees himself as undesirable and likely to be
rejected. The thought of initiating a relationship makes him very
anxious. In actuality, he is handsome, smart, personable, and
caring toward others. However, like many people with low
self-esteem and depression, he cannot see these positive
characteristics in himself. In this example, I selected two of his
upsetting thoughts, identified some of the his primary emotions,
and then evaluated and modified his thoughts using the procedures
described above.
Comments: His original automatic thoughts were marked by
cognitive distortions that selectively filtered the evidence (e.g.,
ignoring evidence contrary to the idea that he is undesirable) and
faulty reasoning (e.g., not having a girlfriend must necessarily
mean that he is undesirable). It was distorted thinking like this
that produced his social anxiety in the first place earlier in his
teens. In turn, the anxiety inhibited him from pursuing
relationships with females. As a result, he felt even more unwanted
and undesirable. Notice how a self-reinforcing vicious cycle tends
to develop between negative distorted thoughts and avoidance
behaviors. This cycle is what is behind many peoples problems with
depression and anxiety.
Troubleshooting cognitive restructuring
Frequently, people say that they have completed the cognitive
restructuring process and they know that their thinking is
distorted but they still feel that it is true. When this occurs,
they may be tempted to conclude that cognitive restructuring isnt
very helpful. However, there are a number of reasons that this
might occur:
1. Failing to fully identify the thoughts driving the emotions
(including interpretations, evaluations, and underlying
expectations). It can be helpful to explicitly answer all of
relevant questions in Part I in writing.
2. Failing to fully challenge and modify the thoughts. Often
people stop once they see their thoughts are distorted, but do not
specifically identify what makes them distorted or come up with
alternative ways of thinking. It can be helpful to explicitly
answer all of relevant questions in Part II in writing, and then to
write out a summary of the alternative way of thinking.
3. The distorted thoughts serve a purpose, and people can be
reluctant to let this go. Remember that distorted thoughts often
are an attempt to protect a person from negative consequences. It
can be helpful to ask, What are the advantages and disadvantages of
believing this thought? Often, there are some advantages, but they
are frequently outweighed by the disadvantages.
4. Often cognitive restructuring is not enough on its own, and a
person needs new learning experiences to convince them of what is
true at a deeper level. This means engaging in new behaviors, often
of the type that the person has been avoiding due to pessimism or
anxiety. This can be where CBT techniques such asbehavioral
activation(for depression) andexposure(for anxiety) can be very
helpful.
5. Finally, it is helpful to remember that it may have taken a
lifetime to develop these patterns of thought, and takes time and
hard work to change them.
More about Cognitive Behavioral Therapy (CBT)
An Introduction to Cognitive-Behavioral Therapy (CBT) CBT
techniques part 1: Cognitive restructuring (you are on this page)
CBT techniques part 2:Behavioral activation CBT techniques part
3:Exposure therapy
Notes
1. This vignette was adapted from:Mind over mood- Change how you
feel by changing the way you think, by Dennis Greenberger &
Christine Padesky.
2. This list of cognitive distortions was partially adapted
from:The feeling good handbook, byDavid Burns. Plume, 1999.
3. These lists of questions were adapted from:Cognitive therapy:
Basics & beyond, byJudith Beck.
4. This semi-fictional male college student is a representative
composite of several clients I have worked with over the
years.--Last updated:
02.05.10--Navigation:Home>Resources>Coping skills &
treatments>Cognitive Behavioral Therapy> Cognitive
restructuring
CBT techniques, part 2: Behavioral activation
Introduction
This is the second in a series of four articles describing the
primary techniques of Cognitive Behavioral Therapy (CBT). Prior to
reading this article, please read myIntroduction to CBTand
mydisclaimerregarding information provided on this website.
This article focuses on a set of techniques called behavioral
activation, which involve helping people to identify and engage in
activities that increase the chances they will have rewarding
experiences. It is very useful in the treatment of depression.
An overview of behavioral activation
Depression often leads to withdrawal, avoidance, and inactivity.
This prevents people from experiencing positive reinforcement that
provides satisfaction and motivation. While it is understandable
that people withdraw when they arent feeling well and avoid what
they are afraid of, ultimately this is detrimental to well-being
and it can become an ingrained habit. Behavioral activation is a
set of techniques for helping people to overcome this habit.
Therapists help their clients to set weekly goals, to identify
possible sources of positive reinforcement, and to schedule and
structure their activities.
I plan to write a more detailed guide to the specific techniques
of behavioral activation. Until then, you can read more about it by
exploring the links provided below.
Online resources regarding behavioral activation
Wikipedia(Behavioral Activation)
Derek Hopko, PhD(behavioral activation researcher)
Christopher Martell, PhD(behavioral activation researcher)
The Society of Clinical Psychology
PDFs available from theCentre for Clinical Interventions
Depression Resources):An overview of behavioral activation;Fun
activities catalog;Behavioral activation worksheet
Book recommendation
An excellent book for the general public is:Overcoming
depression one step at a time: The new behavioral activation
approach to getting your life back, by Michael E. Addis &
Christopher R. Martell. New Harbinger, 2004.
Selected research
Cuijpers P, van Straten A, Warmerdam L. (2007).Behavioral
activation treatments of depression: a meta-analysis.Clinical
Psychology Review, 27, 318326.
Dobson KS, Hollon SD, Dimidjian S, Schmaling KB, Kohlenberg RJ,
Gallop RJ, Rizvi SL, Gollan JK, Dunner DL, Jacobson NS.
(2008).Randomized trial of behavioral activation, cognitive
therapy, and antidepressant medication in the prevention of relapse
and recurrence in major depression.Journal of Consulting &
Clinical Psychology, 76, 468477
More about Cognitive Behavioral Therapy (CBT)
An Introduction to Cognitive-Behavioral Therapy (CBT) CBT
techniques part 1:Cognitive restructuring CBT techniques part 2:
Behavioral activation (you are on this page) CBT techniques part
3:Exposure therapy
Disclaimers
Please see mydisclaimersregarding the information provided on
this website, the links to external information, and my lists of
possible referrals.--Last updated
02.05.11--Navigation:Home>Resources>Coping skills &
treatments>Cognitive Behavioral Therapy> Behavioral
activation
CBT techniques, part 3: Exposure therapy
By Nelson Binggeli, PhD
Introduction
This is the third in a series of four articles describing the
primary techniques of Cognitive Behavioral Therapy (CBT). Prior to
reading this article, please read myIntroduction to CBTand
mydisclaimerregarding information provided on this website.
This article focuses on a set of techniques called exposure
therapy, which help people overcome anxiety by learning to face
their fears in a systematic way. Exposure therapy been shown to be
very effective in treating anxiety disorders, includingGeneralized
Anxiety Disorder,Obsessive Compulsive Disorder,Panic
Disorder,Posttraumatic Stress Disorder,Social Anxiety Disorder,
andSpecific Phobia. This article first describes how anxiety
disorders develop at least partially through classical conditioning
and avoidance. It then presents the principles of exposure
therapy.
Classical conditioning
In order to understand why exposure therapy works, it helps to
understand classical conditioning and its role in the anxiety
disorders. Classical conditioning was first demonstrated by Ivan
Pavlov, a Russian physiologist, in his famous experiments with dogs
around the turn of the 20th century. Pavlov showed that if you
repeatedly ring a bell right before giving food to a dog, it will
eventually come to salivate upon hearing the bell only. The general
principle that Pavlov discovered was that if you repeatedly present
a stimulus that naturally causes a reaction (e.g., food causing
salivation) right after presenting a previously neutral stimulus
(i.e., the bell), an animal will come to react to the previous
neutral stimulus in a similar way.
Classical conditioning forms part of the basis for anxiety
disorders. People with anxiety disorders have come to associate
non-threatening neutral stimuli with either traumatic experiences
or imagined future catastrophes. They have learned to react to a
previously neutral stimulus as if it were an actual threat. For
example someone with a phobia of dogs may experience a stress
reaction just by looking at a picture of a dog. They may rationally
know that the picture cannot hurt them, but nevertheless their
brain triggers the release of adrenaline to help their body either
fight or flee. This illustrates how classical conditioning is an
automatic emotional response that bypasses rational thought.
Classically conditioned responses are recorded deep in the
emotional centers of the brain (i.e., the limbic system). When we
perceive that something is threatening, our emotional centers send
out an alarm. It takes a few more milliseconds for the rational
centers of our brain to process what is happening. When we are
afraid, our body responds more strongly to the alarm from the
emotional centers of the brain than to our rational thoughts. This
is responsible for the phenomenon of knowing that something isnt
threatening and yet still feeling afraid.
In Panic Disorder, people come to fear body sensations that
actually are not harmful. In Generalized Anxiety Disorder, people
react to thoughts and images of possible future negative events
almost as strongly as if they were actually occurring. In
Posttraumatic Stress Disorder, people react to things that remind
them of a traumatic event almost as if the event were actually
occurring in the present. In Social Anxiety Disorder, people come
to associate social situations with visions of being humiliated. In
Obsessive Compulsive Disorder, people develop an exaggerated fear
of not doing something to remove a possible threat, no matter how
unlikely this threat may be.
The role of avoidance
Typically, people tend to avoid these stimuli as much as
possible. While this is understandable, it prevents the emotional
centers of their brain from learning that these stimuli actually
are not threatening. This maintains and may even strengthen the
perception that these stimuli are something to be feared. Over
time, avoidance behavior can become stronger and more pervasive
because it provides relief from anxiety (thought a process called
negative reinforcement). Accordingly, in order to overcome anxiety
and its limiting effect on ones life, one must learn to stop
avoiding.
Exposure therapy
Exposure therapy is a technique for reducing classically
conditioned responses. In exposure therapy, clients voluntarily
agree to be exposed to the very stimuli that trigger the anxiety
response. When people repeatedly expose themselves to stimuli that
they fear and nothing bad happens, the emotional centers of the
brain learn that they can relax in the presence of this
stimuli.
The stimuli may be actual or imagined and it may be confronted
in the therapists office or in real life. Often, people find it
more acceptable to begin with exposure to imagined objects or
events before confronting actual ones. Typically, the exposure
exercises begin with stimuli that might arouse only mild to
moderate levels of anxiety. After several successful exposures,
people often are ready to confront things that are even more
anxiety provoking. Often, the therapist helps the client to develop
coping strategies for managing the anxiety-provoking situation,
which can include relaxation skills, assertive communication
skills, and more rational ways of thinking about situation
(seecognitive restructuring).
Exposure therapy can be challenging for both clients and for
therapists. Confronting stimuli that causes feelings of fear,
helplessness, shame, disgust, or horror is not easy. However, there
is a lot of scientific evidence that it works, and most people find
that ultimately the short-term pain caused by exposure is greatly
outweighed by becoming liberated from classically conditioned fear
responses. In addition, the graduated nature of the exposures
(i.e., starting with less fearful stimuli) and the use of improved
coping strategies make it somewhat less challenging than it might
otherwise be.
There are several theories about why exposure works. The one
that has the most research support is that it works primarily
through the mechanism of habituation. Habituation occurs when the
repeated exposure to a stimulus decreases our responsiveness to it.
For example, we may come to tune out the noise of a loud fan after
being in a room with it for a while. It is also possible that we
replace one form of conditioning for another (this has been called
counterconditioning). Because an anxiety response cannot continue
indefinitely, eventually anxiety decreases during exposure. When
this happens, the association between the stimulus and the anxiety
response is weakened and replaced with an association with a more
relaxed state. Theorists who emphasize cognitive factors argue that
(a) safe exposure may help people think about the stimuli more
objectively, (b) people come to expect that theyll be less anxious
in the presence of the stimuli, and (c) exposure may strengthen the
persons beliefs that they are capable of coping with their
anxiety.
Creating an anxiety hierarchy
The first step in conducting exposure therapy is creating what
is called an anxiety hierarchy. This is a list of the stimuli that
causes an anxiety reaction arranged in a hierarchy according to how
much anxiety each stimuli causes. For example, stimuli that cause
only mild anxiety are listed at the bottom of the list.
More specific information about how to create an anxiety
hierarchy will be provided here soon.
Conducting exposure exercises
More specific information about this will be provided
soon.--Websites for more information
Center for the Treatment and Study of Anxiety, at the University
of Pennsylvania, directed by Edna Foa, PhD
More about Cognitive Behavioral Therapy (CBT)
An Introduction to Cognitive-Behavioral Therapy (CBT) CBT
techniques part 1:Cognitive restructuring CBT techniques part
2:Behavioral activation CBT techniques part 3: Exposure therapy
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