How does CBT work?
Cognitive Behavioural Therapy (CBT) is a collaborative, practical and problem orientated approach to emotional problems whereby the client and therapist work together toward understanding difficulties in terms of the relationships between thoughts, feelings, body responses and behaviour.
What can CBT help with?
NICE recommends CBT in the treatment of the following conditions:
- Anxiety disorders (including panic attacks and post-traumatic stress disorder)
- Obsessive Compulsive Disorder (OCD)
- Schizophrenia and psychosis
- Bipolar disorder
There is also good evidence that CBT is helpful in treating many other conditions, including:
- Chronic fatigue
- Chronic pain
- Physical symptoms without a medical diagnosis
- Sleep difficulties
- Anger management
CBT can be used if you are on medication which has been prescribed by your GP. You can also use CBT on its own. This will depend on the difficulty you want help with.
Cognitive behavioral therapy (CBT) for anxiety
Cognitive behavioral therapy (CBT) is the most widely-used therapy for anxiety disorders. Research has shown it to be effective in the treatment of panic disorder, phobias, social anxiety disorder, and generalized anxiety disorder, among many other conditions. CBT addresses negative patterns and distortions in the way we look at the world and ourselves. As the name suggests, this involves two main components: Cognitive therapy examines how negative thoughts, or cognitions, contribute to anxiety. Behavior therapy examines how you behave and react in situations that trigger anxiety. The basic premise of CBT is that our thoughts—not external events—affect the way we feel. In other words, it’s not the situation you’re in that determines how you feel, but your perception of the situation. For example, imagine that you’ve just been invited to a big party. Consider three different ways of thinking about the invitation, and how those thoughts would affect your emotions.
Situation: A friend invites you to a big party
Thought #1: The party sounds like a lot of fun. I love going out and meeting new people! Emotions: Happy, excited
Thought #2: Parties aren’t my thing. I’d much rather stay in and watch a movie. Emotions: Neutral
Thought #3: I never know what to say or do at parties. I’ll make a fool of myself if I go.
Emotions: Anxious, sad
As you can see, the same event can lead to completely different emotions in different people. It all depends on our individual expectations, attitudes, and beliefs. For people with anxiety disorders, negative ways of thinking fuel the negative emotions of anxiety and fear. The goal of cognitive behavioral therapy for anxiety is to identify and correct these negative thoughts and beliefs. The idea is that if you change the way you think, you can change the way you feel.
Thought challenging in CBT for anxiety
Thought challenging—also known as cognitive restructuring— is a process in which you challenge the negative thinking patterns that contribute to your anxiety, replacing them with more positive, realistic thoughts.
This involves three steps:
1) Identifying your negative thoughts. With anxiety disorders, situations are perceived as more dangerous than they really are. To someone with a germ phobia, for example, shaking another person’s hand can seem life threatening. Although you may easily see that this is an irrational fear, identifying your own irrational, scary thoughts can be very difficult. One strategy is to ask yourself what you were thinking when you started feeling anxious. Your therapist will help you with this step.
2) Challenging your negative thoughts. In the second step, your therapist will teach you how to evaluate your anxiety-provoking thoughts. This involves questioning the evidence for your frightening thoughts, analyzing unhelpful beliefs, and testing out the reality of negative predictions. Strategies for challenging negative thoughts include conducting experiments, weighing the pros and cons of worrying or avoiding the thing you fear, and determining the realistic chances that what you’re anxious about will actually happen.
3) Replacing negative thoughts with realistic thoughts. Once you’ve identified the irrational predictions and negative distortions in your anxious thoughts, you can replace them with new thoughts that are more accurate and positive. Your therapist may also help you come up with realistic, calming statements you can say to yourself when you’re facing or anticipating a situation that normally sends your anxiety levels soaring.
To understand how thought challenging works in cognitive behavioral therapy, consider the following example: Maria won’t take the subway because she’s afraid she’ll pass out, and then everyone will think she’s crazy. Her therapist has asked her to write down her negative thoughts, identify the errors—or cognitive distortions—in her thinking, and come up with a more rational interpretation. The results are below.
Challenging Negative Thoughts
Negative thought #1: What if I pass out on the subway? Cognitive distortion: Predicting the worst. More realistic thought: I’ve never passed out before, so it’s unlikely that I will on the subway.
Negative thought #2: If I pass out, it will be terrible! Cognitive distortion: Blowing things out of proportion. More realistic thought: If I faint, I’ll come to in a few moments. That’s not so terrible.
Negative thought #3: People will think I’m crazy. Cognitive distortion: Jumping to conclusions. More realistic thought: People are more likely to be concerned if I’m okay.
Replacing negative thoughts with more realistic ones is easier said than done. Often, negative thoughts are part of a lifelong pattern of thinking. It takes practice to break the habit. That’s why cognitive behavioral therapy includes practicing on your own at home as well. CBT may also include:
Learning to recognize when you’re anxious and what that feels like in the body
Learning coping skills and relaxation techniques to counteract anxiety and panic
Confronting your fears (either in your imagination or in real life)
Exposure therapy for anxiety
Anxiety isn’t a pleasant sensation, so it’s only natural to avoid it if you can. One of the ways that people do this is by steering clear of the situations that make them anxious. If you have a fear of heights, you might drive three hours out of your way to avoid crossing a tall bridge. Or if the prospect of public speaking leaves your stomach in knots, you might skip your best friend’s wedding in order to avoid giving a toast. Aside from the inconvenience factor, the problem with avoiding your fears is that you never have the chance to overcome them. In fact, avoiding your fears often makes them stronger. Exposure therapy, as the name suggests, exposes you to the situations or objects you fear. The idea is that through repeated exposures, you’ll feel an increasing sense of control over the situation and your anxiety will diminish. The exposure is done in one of two ways: Your therapist may ask you to imagine the scary situation, or you may confront it in real life. Exposure therapy may be used alone, or it may be conducted as part of cognitive behavioral therapy.
Rather than facing your biggest fear right away, which can be traumatizing, exposure therapy usually starts with a situation that’s only mildly threatening and works up from there. This step-by-step approach is called systematic desensitization. Systematic desensitization allows you to gradually challenge your fears, build confidence, and master skills for controlling panic.
Facing a fear of flying
Step 1: Look at photos of planes.
Step 2: Watch a video of a plane in flight.
Step 3: Watch real planes take off.
Step 4: Book a plane ticket.
Step 5: Pack for your flight.
Step 6: Drive to the airport.
Step 7: Check in for your flight.
Step 8: Wait for boarding.
Step 9: Get on the plane.
Step 10: Take the flight.
Systematic desensitization involves three parts:
Learning relaxation skills. First, your therapist will teach you a relaxation technique, such as progressive muscle relaxation or deep breathing. You’ll practice in therapy and on your own at home. Once you start confronting your fears, you’ll use this relaxation technique to reduce your physical anxiety response (such as trembling and hyperventilating) and encourage relaxation.
Creating a step-by-step list. Next, you’ll create a list of 10 to 20 scary situations that progress toward your final goal. For example, if your final goal is to overcome your fear of flying, you might start by looking at photos of planes and end with taking an actual flight. Each step should be as specific as possible, with a clear, measurable objective.
Working through the steps. Under the guidance of your therapist, you’ll then begin to work through the list. The goal is to stay in each scary situation until your fears subside. That way, you’ll learn that the feelings won’t hurt you and they do go away. Every time the anxiety gets too intense, you will switch to the relaxation technique you learned. Once you’re relaxed again, you can turn your attention back to the situation. In this way, you will work through the steps until you’re able to complete each one without feeling overly distressed.
Complementary therapies for anxiety disorders
As you explore your anxiety disorder in therapy, you may also want to experiment with complementary therapies designed to bring your overall stress levels down and help you achieve emotional balance.
Exercise is a natural stress buster and anxiety reliever. Research shows that as little as 30 minutes of exercise three to five times a week can provide significant anxiety relief. To achieve the maximum benefit, aim for at least an hour of aerobic exercise on most days. Relaxation Techniques: Accessing the Relaxation Response Relaxation techniques such as mindfulness meditation and progressive muscle relaxation, when practiced regularly, can reduce anxiety and increase feelings of emotional well-being.
CBT for Depression
Cognitive behavioral therapy (CBT) is an effective treatment for depression. At the heart of CBT is an assumption that a person’s mood is directly related to his or her patterns of thought.
Negative, dysfunctional thinking affects a person’s mood, sense of self, behavior, and even physical state. The goal of cognitive behavioral therapy is to help a person learn to recognize negative patterns of thought, evaluate their validity, and replace them with healthier ways of thinking.
At the same time, therapists who practice CBT aim to help their clients change patterns of behavior that come from dysfunctional thinking. Negative thoughts and behavior predispose an individual to depression and make it nearly impossible to escape its downward spiral. When patterns of thought and behavior are changed, according to CBT practitioners and researchers, so is mood.
Anyone with mild or moderate depression can potentially benefit from cognitive behavioral therapy, even without taking medication.
A number of studies have shown CBT to be at least as effective as antidepressants in treating mild and moderate depression.
Studies also show that a combination of antidepressants and CBT can be effective in treating major depression.
CBT for Low Self Esteem
In order to overcome low self-esteem it’s necessary to break the cycle that keeps it going. Cognitive Behaviour Therapy (CBT) is an ideal approach for tackling low self-esteem, because it provides a clear framework for understanding how the problem developed and what keeps it going. CBT focuses on thoughts, beliefs and opinions, but also provides a practical approach for changing those beliefs by changing behaviour. It encourages you to try out new ways of behaving, and to observe the effect that this has on the way you feel about yourself. In this way you can learn to:
• notice self-critical thinking and nip it in the bud
• counter the bias against yourself by focusing on your skills
• change the Rules for Living that cause you to enter the vicious cycle
• tackle your Bottom Line.
What is low self-esteem?
Self-esteem is an aspect of the way we view ourselves. It’s different from self-image, which might describe a whole range of characteristics (such as ‘I’m British’ or ‘I’m female’) but without implying whether they are good or bad. Self-esteem refers to the overall opinion we have of ourselves and the value we place on ourselves as people. Low self-esteem means that the tone of this opinion is negative: for example, ‘I’m unlovable’ or ‘I’m useless’. Of course most of us have mixed opinions of ourselves, but if your overall opinion is that you are an inadequate or inferior person, if you feel that you have no true worth and are not entitled to the good things in life, this means your self-esteem is low. And low selfesteem can have a painful and damaging effect on your life.
What causes low self-esteem?
The beliefs you have about yourself often appear to be statements of fact, although actually they’re really only opinions. They are based on the experiences you’ve had in life, and the messages that these experiences have given you about the kind of person you are. If your experiences have been negative, your beliefs about yourself are likely to be negative too. Crucial experiences that help to form our beliefs about ourselves often (although not always) occur early in life. What you saw, heard and experienced in childhood – in your family, in the wider community and at school – will have influenced the way you see yourself. Examples of early experiences that could lead to your thinking badly of yourself include:
• systematic punishment, neglect or abuse
• failing to meet parental standards
• failing to meet peer-group standards
• being on the receiving end of other people’s stress or distress
• belonging to a family or social group that other people are prejudiced towards
• an absence of praise, warmth, affection or interest
• being the odd one out, at home or at school
Sometimes negative beliefs about yourself are caused by experiences later in life, such as workplace bullying or intimidation, abusive relationships, persistent stress or hardship, or traumatic events.
CBT for Post Traumatic Stress Disorder (PTSD)
CBT for PTSD Research shows that cognitive behavioural therapy it is the most effective type of counseling for PTSD and its aftermath. Traumatic events can often be very difficult to come to terms with, but confronting your feelings and seeking professional help is often the only way of effectively treating PTSD.
It is possible for PTSD to be successfully treated many years after the traumatic event occurred, which means it is never too late to seek help.
Trauma-focused CBT uses a range of psychological treatment techniques to help you come to terms with the traumatic event. For example, your therapist may ask you to confront your traumatic memories by thinking about your experience in detail. During this process your therapist will help you cope with any distress you feel, while identifying any unhelpful thoughts or misrepresentations you have about the experience.
By doing this, your therapist can help you gain control of your fear and distress by changing the negative way you think about your experience, such as feeling that you are to blame for what happened or fear that it may happen again. You may also be encouraged to gradually restart any activities you have avoided since your experience, such as driving a car if you had an accident.
A course of treatment usually involves 8-12 weekly sessions of trauma-focused CBT.