How does Cognitive Behavioural Therapy really work?
How does cognitive behavioural therapy (CBT) work?
In the following example, you may notice the way in which anxiety-related thinking can have a negative impact. A lonely high school student wants to talk to classmates to make friends. But every time she has the opportunity to do so, anxious thoughts show up: “They’ll see how nervous I am. They’ll think I’m stupid and awkward.” As these thoughts flood her mind, her throat tightens, her mouth goes dry, and she thinks she won’t be able to say a word. She copes by sitting by herself and does not try to start a conversation. She then thinks, “I’m a loser,” and is likely to continue avoiding talking to classmates in the future.
CBT teaches you to recognize the mistakes in your thinking about what would happen if you dared to act in a way that aligns with your values. Through therapy, you will learn to apply your reasoning skills and powers of observation to situations in your life that are leading to anxiety. Like a scientist, you will learn how to test your ideas to determine how realistic they are. When you reduce the distortions and inaccuracies in your thinking, you will decrease your anxiety and develop a more helpful approach to dealing with situations you fear.
What will I learn in CBT?
You will learn to recognize your thoughts when you feel anxious or notice the physical signs of anxiety. Often these thoughts seem to pop up automatically and may have been triggered by an immediate challenge — the need to give a talk, visit a doctor, take on a new responsibility at work, or interact with others. Or you may have thoughts related to the possibility of a more distant event, such as getting married or divorced, having a heart attack or accident, or failing in your job. In CBT, these thoughts are called automatic thoughts.
When you notice that you are becoming anxious or that your anxiety has suddenly increased, ask yourself:
“What just went through my mind?”
Look for thoughts and mental pictures. Remind yourself: Even though my thoughts and images seem accurate, they may not be. Because of anxiety, I may be overestimating threats and underestimating my ability to effectively cope. Having learned to identify your automatic thoughts, you will now begin to evaluate them. You will learn:
To look for evidence that supports or negates your thoughts
To consider the most likely or realistic future outcomes
To consider the consequences of repeating anxiety-related thoughts to yourself
To apply advice you would give to friends or family members in the same situation
To problem solve what to do next
You will also learn that each anxiety experience is time-limited and that you have skills to tolerate it, making you less fearful of experiencing anxiety, and increasing your confidence.
You will also focus on some key problems in your life and develop greater skills in solving problems, which leads to living a life that is more consistent with your aspirations and values. The child mentioned in the example above, brainstormed with her therapist to come up with a number of ways to start a conversation, used role-playing to practice, and read “coping cards” (which they had composed in therapy) a more accepting and non-judgmental manner. Mindfulness practices for anxiety can help you feel less overwhelmed with emotion and learn that when you give up trying to control anxiety, it becomes less distressing.
What are typical thinking errors?
When you keep track of your anxiety-producing thoughts, you may find that the errors in your thinking fall into these general categories:
Exaggerating: a magnified sense of threat, even in the face of objective evidence to the contrary. A parent had a fear that her child was going to die while she was out of town. Her anxiety led her to search out and read news articles about teens dying. She could not recognize the actual probability of the death of an adolescent. Furthermore, she underestimated her child’s positive qualities, like their street smarts and sense of responsibility.
Catastrophizing: When anxious people anticipate danger or difficulty, they sometimes perceive disaster as the probable outcome. An anxious man facing a relatively simple surgical procedure fears that he will be incapacitated or die.
Over-generalizing: One negative experience, such as being turned down for a promotion, may translate into a law governing one’s entire existence: “I’ll never get anywhere in life. What if I don’t succeed?”
Ignoring the Positive: Anxious people overlook or discount the indications of their own ability to cope successfully, forget the positive experiences and successes of the past, and anticipate only insurmountable problems and unendurable suffering in the future. An anxious musician forgets about or discounts his record of good performances. He also ignores the fact that he shares the responsibility of a good performance with his fellow band members.
How is the action plan used?
The action plan is an important part of therapy and consists of making changes between sessions. Since you will be learning methods for coping that will be applicable throughout life, carrying out action plan assignments not only strengthens your ability to use the strategies developed in therapy but also provides a way to test your beliefs in real-life situations. In addition to evaluating your automatic thoughts, you will learn how to enter anxiety-producing situations that are in line with your aspirations and values in a systematic, manageable way. Here are some of the ideas you can keep in mind as you practice your new techniques:
Before confronting a valued anxiety-producing situation, consider your strengths and resources. What do you have going for you?
You may be thinking about only the worst possible outcome of a situation. Ask yourself, “How likely is it that this will happen? How could I cope if it did happen?” Then think about what the best possible outcome might be. Finally, look for something in between—what is the most realistic outcome of this situation?
It is very important that you stop avoiding feared situations. Remind yourself why following through with this situation is consistent with your values and aspirations in life. If you feel overwhelmed, do it gradually. For instance, if you have a fear of elevators, you can “practice” with a friend or your therapist, just a few floors at a time.
When you are already in the midst of a challenging situation and anxiety begins to take hold, remind yourself that while anxiety is uncomfortable, it is not dangerous. It does not necessarily mean that there is any danger. It’s worth experiencing anxiety if it means you’re living a life that’s meaningful. Practice tolerating—and accepting—the anxiety and give yourself credit when you do so.
Making the most of therapy
Setting goals provides motivation to change. If you have a clear picture of how you would like your life to be if you were free of anxiety, you will know what you are working toward. Share your ideas with your therapist so they can help you reach your goals.
Remember that you can only get out what you put in. Significant changes require effort. It will take time and effort to isolate old thought patterns and develop ways to counteract and modify them, especially if you have been suffering from anxiety for a long time.
Be aware that there are usually others who can lend a helping hand if you need them. Your extended family, relatives, friends, coworkers, health professionals, and others interested in your wellbeing are all potential participants in your progress. Learn to call upon them for understanding and help.
Be conscientious in the use of techniques learned in therapy. Although therapy itself is time-limited, the methods you learn are applicable throughout life. No one is forever free of emotional problems, but you will find that anxiety need not dominate your existence.
And, finally, permit yourself the pleasure of feeling excited about exploring new ways to meet life’s challenges. The very fact that you have shown enough initiative to seek help indicates hope and expectation. As therapy progresses and anxiety recedes, that spark of hope will kindle a new enthusiasm for daily living. Be prepared to work for it.