Cognitive Behavioral Therapy (CBT) is one of the most common forms of psychotherapy available today. It is a therapy module based heavily in research, particularly in validation theory. This skills acquisition therapy helps patients to learn the skills they need and, eventually, become their own therapist. Because the goal of CBT is for patients to no longer need their therapist, this is often a time-limited therapy, lasting perhaps 12 sessions. However, some patients may use CBT for longer periods of time.
In this blog, let’s discuss the fundamentals of CBT and how it can help with depression.
Formation of CBT
Aaron T. Beck is recognized as the father of CBT. During the 1960s, he noticed that many of his patients suffering from depression referenced automatic, negative thought patterns that drastically impacted their worldview and their behaviors. One patient, for instance, referenced worrying that she was boring people all the time. He theorized that depression was anger turned inward, and that addressing these negative thought patterns could change the patient’s behavior and mood.
His early attempts of CBT were so successful in fact that he found he often “ran himself out of business.” Patients picked up the skills they needed to cope and found they no longer needed therapy, leaving him with fewer clients. Fortunately, the University of Pennsylvania took an interest in Beck’s work and he took on a career there, teaching research with respect to CBT.
Different Schools of CBT
There are a few different approaches to CBT. Some therapists focus more on the cognitive aspects while others focus on the behavior. There are manualized forms of CBT based on universal procedure, as well as evidence-based forms of CBT based on the patient’s experience.
Some forms of CBT involve exposure therapy, such as exposure and response prevention (ERP) for OCD or prolonged exposure for PTSD. There are a few therapies that have been formed based on CBT, including Dialectical Behavioral Therapy (DBT) or Acceptance and Commitment Therapy (ACT).
However, there are a few things that most forms of CBT typically have in common:
- Behavior as the main vehicle of change
- A focus on mindfulness and experiencing the present moment
- A goal to increase adaptive functioning and reduce experiential avoidance
Misconceptions About CBT
Although CBT is so commonly used in psychotherapy, there are a number of misconceptions about this form of therapy — among clients and clinicians alike. Some of the most common misconceptions can be:
It’s Invalidating
Many people feel that CBT is about invalidating your feelings and beliefs. However, a good CBT therapist focuses less on challenging your emotions and rather on reevaluating your beliefs. Most patients have their core beliefs for a reason. The therapist will help you determine when you formed that core belief, why, and whether or not it still serves you.
It Tells the Patient Their Problems Are All In Their Heads
Sometimes patients with depression have a distorted view of themselves and of reality. However, sometimes the root of their depression comes from a very concrete reality in their lives. In CBT, your therapist will help you determine whether you’re struggling with a distorted view of reality or a reality that you need to work through.
It’s Not Fun
Another misconception is that while CBT is effective, it’s not particularly fun and can be too serious or heavy for the patient. This is because in the past, many forms of therapy felt the need to take themselves very seriously in order to be taken seriously. However, CBT can use creative, refreshing, and even funny approaches to teach patients the skills they need.
The Fundamentals of CBT
To understand CBT, you first need to understand the fundamental principles of the theory and what CBT aims to treat.
Core Beliefs & Immediate Thoughts
Everyone has immediate thoughts and core beliefs. Core beliefs are the thoughts at the center of your view of yourself and the world around you. Immediate thoughts are filtered through that core belief.
For those with depression, core beliefs are often negative. For instance, “I’m unlovable” or “I’m stupid.” With a strong negative core belief, you may see confirmation of your core belief in your perception of situations. You may also struggle to see positive contradictions of that core belief. For instance, if you find yourself to be ugly, and someone tells you you’re pretty, you may convince yourself that they’re lying to be nice.
By reorienting the core belief, you can change your immediate thoughts and — hopefully — your behavior.
The Behavioral Cycle
For every behavior, there is a situation, a thought process, and a reaction. The situation you find yourself in feeds into your core belief, which leads to a thought or perception of the situation. Based on that thought, you will react to the situation in a particular way. In some cases, your reaction may seem to confirm your thoughts.
For instance, if your core belief is that you’re annoying, you may feel some anxiety about being at a work party or a networking event. Because you believe yourself annoying, you may stick to the walls and not talk to anyone for fear of “bothering them.” In doing so, you miss out on any feedback that could contradict your core belief and may feel that the lack of interactions you had at the event are evidence that you are, in fact, annoying.
Thought Processes
The first two sections deal with the content of your thoughts. But the thought processes also matter. Some harmful thought processes may include:
- Thought blocking
- Excessive worry
- Rumination
- Search for certainty
These can all be forms of avoidance. With thought blocking, you might try to shove the uncomfortable thought away without reflecting on it. Excessive worry and rumination, while it may seem like the opposite, can also be a form of avoidance. In a search for certainty, you may immediately take to trying to confirm your worries even when you’re unable to do so. These thought processes prevent you from being present in the moment and experiencing your emotions fully.
Experiential Avoidance
Experiential avoidance is a major cause of human suffering, and it is a key part of many mental illnesses. Experiential avoidance is effectively pretending not to be in a situation or not to feel what you’re feeling. With experiential avoidance, you might have major avoidance — a complete refusal of distressing situations — or minor avoidance — such as distraction or rumination to pull you out of the moment.
There are also underbehaviors and overbehaviors. You may have underbehaviors in experiential avoidance such as staying quiet or trying to be invisible. In a similar situation, an overbehavior could be adopting a hypersocial or overtly funny persona. Both of these are avoidant of the experience.
The problem with experiential avoidance is that in avoiding the present moment, you don’t receive any feedback from your environment. Without anything to push back against a negative core belief, you will be inhibited from feeling.
Ways People Avoid Emotions
There are a number of ways that people can avoid their feelings, including:
- Mood dampening
- Substance use
- Avoiding any time alone
- Sleep
One way to push back against this is with exposure therapy. When humans interact with something repetitively, such as fear of being alone, the emotion decreases in intensity. An example of exposure therapy in this case can be to gradually increase time spent alone and awake, and track that time spent alone. Then look back at any information that pushes back against your cognitive filter.
The Experiential Approach
The experiential approach is key to CBT. It is the willingness to fully experience the moment, and it is the opposite of experiential avoidance. The point of the experiential approach is not to “feel things correctly” but rather to “feel things, correctly” by embracing your emotions in an adaptive way.
Emotions are an evolutionary process and they always have a purpose. By being mindful, you can determine if your emotions match the situation you’re in, which can help to propel proactive behavior.
Willingness
One skill that is important to CBT is the process of increasing willingness to embrace the present moment. For some CBT patients, this could be a matter of being told to experience a situation. In changing their behavior, they can push back against their negative core beliefs.
However, some may need some cognitive work to ease them into that willingness. You could remove your safety behaviors one at a time to dip your toes into willingness. After each attempt, you will reflect what you learned from the experience to your therapist to ensure that you’re beginning to break through that cognitive filter.
How CBT Therapy Works
The first step of a CBT therapy session is to examine evidence for and against a particular thought or emotion to determine if the thought is distorted. If it is, you will work with your therapist to form a reality-based belief. It’s important to get as close to the core belief as possible in this discussion. If it is based in reality already, you can problem solve to cope with the situation.
Next, you will work on engaging in experiential approach behaviors. This involves feeling your feelings without your usual armor, learning a healthy thought process, and in some cases, exposure therapy. A big portion of this is reflecting on what you learned from the experiential approach behaviors, alone and with your therapist. The goal for CBT is not to feel happy all the time but rather to feel your feelings adaptively. When you’re sad, allow yourself to feel sad. When you’re happy, allow yourself to feel happy.
CBT For Depression
All emotions have a purpose, and there is good to be found in slowed down, introspective moods. In moderation, slowing down allows you to reflect on what’s going wrong. By taking time to process, you can come up with an idea to proactively fix the situation. However, when you have overly negative views of yourself — as is often the case for those with depression — you can often create a problem your brain is unable to solve. “I’m unlovable” or “I’m stupid” are not things your brain can problem solve for.
This causes the brain to slow down too much, which in turn impacts your behavior and lifestyle. Those with depression have a tendency to internalize their experiences — blaming themselves rather than seeing the situation objectively, to see issues as global rather than specific, and to see situations as unchangeable rather than transient. One example would be doing poorly on a test. A depressed person might say “I did poorly on this test because I’m stupid.” It focuses on internal beliefs rather than considering external factors: maybe they didn’t have time to study, went into the test without enough sleep, or didn’t have enough time to finish the test. It also ignores the possibility that performance could change with time and effort.
Because the cognitive filter in depression is often rather strong, CBT for depression can be a slower process. Depressed patients with strong negative core beliefs may seem resistant to attempts to contradict their core belief, pushing back with, “I don’t believe that.” It helps to go in slower steps, reevaluating small portions of the core belief and growing from there. In CBT, patients with depression may also be encouraged to get out and do more, contradicting the depression’s desire to ruminate and remain inactive.
CBT is one effective way to treat depression, as well as other mental health conditions like anxiety, OCD and PTSD. Are you interested in trying CBT for yourself? We have a number of skilled and compassionate clinicians experienced in CBT who can help. Contact Rivia Mind today to learn more or to schedule a free 15-minute consultation.
