COGNITIVE behavioural therapy (CBT)

What we think has the capacity to affect:

• how we feel;
• what we do/avoid;
• our physiological reactions (e.g., headache, palpitations, abdominal discomfort, sweatiness, muscle tension, etc.).

Here are some things to consider about our thoughts:

• Just because we believe something, doesn’t mean it’s true, and;
• We can acquire fresh perspectives that are more reasonable and empowering through a process of self-reflection.

Most situations remain neutral until we assign meaning based on how we interpret the situation.

Consider the following:

Situation: first day of school.

Person A: I can’t wait to see all my friends again and take one step closer to my dream of becoming an ophthalmologist.

• Emotions: happy
• Behaviour: on-time and ready-to-learn, participating and asking insightful questions
• Physiology: focused, smiling

Person B: School is too hard; I won’t be able to do it. I just want to stay home and play video games. School is for losers.

• Emotions: sadness, boredom
• Behaviour: tardy, not compliant with homework, falling asleep in class
• Physiology: fatigue, spacing out, flat facial expression, headache, stomach ache (enough to miss school [and play video games]; note that missing school is a behaviour)

Person C: I’m nervous that everyone is going to make fun of my acne.

• Emotions: anxiety
• Behaviour: avoidant, introverted
• Physiology: sweaty, palpitations, nervous, choking sensation, stuttering

As you can see, the first day of school is the first day of school; it is a constant in this equation, that is, it doesn’t change. It is made up of the same building, with the same people, with the same activities and opportunities. Yet, it is experienced differently by Persons A, B and C.

Answer: Automatic thoughts (AT).

Automatic Thoughts (ATs) are thoughts we have automatically in reaction to a situation. They are more like a habit that we have adopted and fine-tuned over the years, in part by operant conditioning. That is, for the most part, our environment molded us to whip out specific ATs for different situations. Sometimes we are aware of ATs, most of the times we are not. One is more likely to be aware of how they feel or how they react than of what thought automatically races through one’s mind triggering the emotions and behaviours.

 

For example, take the commonly experienced emotion, anger.

Situation: someone cuts you off.

Reaction: You get angry, yell, tense your muscles, flash the finger.

What happened to take you from the situation (i.e., having been cut off) to the reaction? What was the thought that kindled that reaction?

Possibly, “That person doesn’t care about my life. That person is disrespectful and shouldn’t do that”.

• Then it’s easy to see why one would get angry.

But are there other possible explanations for why the person cut you off? (see Socratic questioning below)

• e.g., Did that person really target you? Perhaps that person spilled coffee? An animal jumped out in front of the car? That person didn’t see you? These are all plausible explanations without changing the facts (i.e., that that person cut you off).

 

Evaluating the validity of ATs can be broken down into two general steps:

1. To become aware of them.
2. To develop the skills to modify them to one’s advantage.

 

Fostering awareness

The flywheel to getting at the AT is paying attention to shifts in your emotions, behaviours and physiology.

e.g., 

Person A: I feel happy. My body feels relaxed. I just asked that person out to the dance. What am I thinking right now?

Person B: I feel sad. My body feels heavy and burdened. I just ignored everything the teacher said. What am I thinking right now?

Person C: I feel anxious. My body feels tense and sweaty. I am avoiding everyone. What am I thinking right now?

 

Paying attention to shifts in emotions, behaviours and physiology can be enhanced through training:

1. Applied mindfulness intervention – present moment awareness;
2. Awareness of thoughts;
3. Expressive writing;
4. Psychological techniques like disruption theory exercise (acknowledging your emotions; labelling them; observing them in witness-like state, as if you were looking back on yourself from the future or you are seeing it drift down the river);
5. Relaxation training (i.e., Progressive muscle relaxation, guided visualization, autogenic training, diaphragmatic breathing, passive muscle relaxation).

 

Once we identify and acknowledge the AT, then we need to evaluate it…does it hold water?

 

Developing skills in evaluating and consciously shaping ATs

This is usually done by what is called Socratic questioning. This systematic method of questioning is named after its namesake, the famous philosopher, Socrates. One of his students, also famous, was Plato. They lived over 400 years BC. This was the method Socrates used to teach his students: by setting them up to reach the answer through a systematic series of questioning. 

Patients will learn how to do this themselves, just like Plato did!

 

Examples of Socratic questioning:

1. What is the evidence that my thought is true? What is the evidence that my thought is not true?
2. What’s an alternative explanation or viewpoint?
3. What’s the worst thing that could happen and how would I cope if it did?
4. What’s the best that could happen?
5. What’s the most likely outcome?
6. What is the effect of telling myself this thought?
7. What could be the effect of changing my thinking?
8. What would I tell someone else if he/she viewed this situation in this way?
9. What should I do now?

 

e.g., 

Person A:

• AT – I’m going to own this year in school.
• Evaluation – No need, it is empowering and functionally satisfactory. This student should stick to that AT.

Person B:

• AT – I’m going to fail again, so I might as well not try.
• Evaluation – How will things likely work out for me if I keep thinking that? What are my chances of turning things around if I keep thinking that? What are somethings I can do now to improve my chances of improving. What are some situations I have experienced in which I succeeded and how did I pull it off?

Person C:

• AT – Everyone is going to make fun of the way I look.
• Evaluation – What are the chances of that when half the kids in school have acne? When was the last time someone made fun of me because of the way I looked? (My twin makes fun of my looks more than anyone and we’re best friends.) Why are the people closest to me love me? Why do I love the people closest to me?

Answer: Core Beliefs.

Core Beliefs are beliefs about ourselves, others and the world, that we started developing in childhood. The are fundamental beliefs that are prejudices we have about ourselves. They are rigid and overgeneralized.

E.g., 

Person A: I’m competent.

Person B: I’m incompetent.

Person C: I’m unattractive.

People don’t consciously whip out this belief. It’s sitting there, ready to be poked at and woken up to spit out an AT in the face of a situation (e.g., first day of school).

Core beliefs take a lifetime to develop. Often, we accepted others’ opinions as truth after they repeated it so many times (i.e., you can’t do ANYTHING right) in the absence of any evidence to support that. Adding statements like “just like your father” doesn’t count as valid proof of the argument “You can’t do anything right”; although, doing so may passively aggressively help sneak that suggestion past our defense where it then finds a throne on which to sit and reign over our core beliefs.

 

“What gets us into trouble is not what we don’t know. It’s what we know for sure that just ain’t so.” 

– Mark Twain

 

Then, you started to live your life as if that were true; and then it becomes a self-fulfilling prophecy.

• You don’t apply yourself in school because you already believe you can’t do anything right, and sure enough, you end up with D’s, further backing up what your mom used to say.
• Or, you may blame yourself for things that aren’t your fault. E.g., I got a D, therefore, I can’t do anything right. (Inconveniently, the person overlooks that it had something to do with the fact that the teacher was ineffective, or the material was too hard for our level as most of the class got D’s, or that I got a D because I didn’t apply myself.)
• Or when something does go right, you find some excuse to explain how this “impossible” event occurred as it couldn’t have possibly been intentional as “you can’t do anything right”. E.g., I scored that goal in soccer, but the anyone could have tapped that in.
• Or when something does go right, you don’t pay it much attention. Rather, you choose to focus on the situation that seems to make sense to you, that seems to back up the core belief “I can’t do anything right”. E.g., That person just swerved into oncoming traffic and almost collided with me head-on. I was able to maneuver out of the way but hit the curb and got a flat tire…I can’t do anything right.

 

This can be represented pictorially as depicted below (i.e., The information-processing model). The bubble represents the core belief that exists inside of us. To us, it defines who/what we are. Here is how this works:

1. Everything I think/feel is tainted by this lens. I can only entertain thoughts that are consistent with this belief: “I can’t work, I didn’t clean the house, I was mean to my mother”. All these beliefs are all consistent with “I can’t do anything right.”
2. I had a birthday brunch with my brother. Wait, this doesn’t have the stink of the passcode “I can’t do anything right”. 
   • Deny passage into the bubble (“FAIL”)
   • Let me add something stinky like “but I wasn’t nice to him” (“PASS in my friend, ‘you can’t do anything right’, just like us”)
3. I helped the neighbour shovel her driveway. (“IGNORE”, doesn’t fit into the bubble).

 

What does it take to develop disempowering core beliefs?

• Lifetime of having that belief communicated to you, directly (e.g., people telling you that “you can’t do anything right”); or indirectly (e.g., always being picked last for sports).
• An isolated event (e.g., a break-up of a long-term relationship that leaves you develop the belief “I can’t do anything right”).

 

A note on Core Beliefs:

• Core Beliefs may only be active in certain contexts (e.g., when you are with a specific group, or when you are feeling depressed, or when you are experiencing a headache) and may not generalize to all facets of life.

Core beliefs can be seen to lead to an intermediate culture that is already preset and ready to go (and throw up an AT) in the face of a situation.

E.g., Person B.

Core belief: “I can’t do anything right”

Attitude: “It’s terrible to fail”

Rule: “Just give up before you try (and fail)”

Assumption: “If you fail, you are incompetent. If you don’t even try (and don’t fail) you are not incompetent.”

 

Situations that can trigger ATs:

1. Situation (e.g., first day of school)
2. Thoughts (e.g., thinking about your first assignment)
3. Memory (e.g., thinking about your last year’s report card)
4. A sensory perception (e.g., sight of your mom’s forehead vein pulsating; your father sternly calling your name, the scent of your aunt Sheila, the awareness of her heart beating)
5. An emotion (e.g., a new mother feeling frustrated may illogically conclude that she is a bad mother).
6. A behaviour (e.g., loafting in bed)
7. A health condition (e.g., a headache).

 

How to people cope with these negative thoughts, behaviours and emotions?

Coping strategies are like a toolbox of strategies we have ready at the helm to help cope with negative emotions, behaviours and, if we are observant enough to catch them, thoughts. Sometimes people use the same strategy to soothe many different problems; and sometimes they use different ones for different problems. The coping strategies are born from one’s core beliefs. If someone sees oneself as inadequate, that person will develop coping strategies to compensate for what they perceive to be inadequate about them.

E.g., 

Person A: I’m feeling challenged. I’ll go for a run and clear my mind and then make a strategy.

Person B: I’m feeling challenged. I’ll play video games, take the easiest classes that I can coast through and play sick so I can skip school.

Person C: I’m feeling challenged. I’ll avoid people, avoid social situations, and spend a lot of time staring at myself in the mirror, wear a hat to cover my face, slouch so people don’t notice me.

 

Coping skills can be analyzed in many different ways. They can be classified as:

1. Internal vs. external
   • Internal: things we do mentally to relax
     • Relaxation strategies, coping cards, aspirations/visualization board, AP, cost-benefit analysis, etc.
   • External: behaviours we do to relax
     • watch a movie, phone a friend, go for a walk, exercise, etc.
2. Adaptive vs. maladaptive
   • Adaptive: things that are good for us and help us solve the problem
     • Going for a run, assertiveness communication, positive self-talk, time management skills, etc.
   • Maladaptive: things that ultimately are not good for us and don’t help us solve the problem
     • Avoiding people, drinking alcohol, using drugs, expressing anger, binge eating, ruminating on things, etc.
3. Affective vs. Physical vs. Cognitive vs Sensory
   • Affective: spending time with your pet
   • Physical: exercise, muscle relaxation exercises, etc.
   • Cognitive: mindfulness exercises, distraction techniques, playing an instrument, etc.
   • Sensory: pleasant scents (e.g., lavender, sage, etc.), listening to relaxing music

 

Sometimes, people have a limited repertoire of coping skills and need to search for some. Adopting some may require you to keep an open-mind, and you may acquire a taste for it after some time. Breathing training may not be your cup of tea at first, but once you learn how to do the resonance frequency breathing, you may really start to like it. Kind of like, when you first start music lessons, it can be boring just learning the basics. But once you learn to put it all together in a song, you may really start to enjoy it.

Cognitive Behaviour Therapy (CBT) is about structuring people’s problems in a way where we can identify their thoughts, feelings and behaviours and why they are so. Then, to identify why those (maladaptive) thoughts came to be by identifying the core beliefs from which they are borne. Then, identifying how those core beliefs likely developed from the patient’s previous experiences. And, once light is shed on the whole picture, teaching the patient to become aware of these connections between beliefs, thoughts, emotions, behaviours, attitudes, rules and assumptions. Then having the patient, through Socratic questioning, evaluate those maladaptive thoughts and beliefs for their validity; or are there better explanations? In cognitive terams, when dysfunctional thoughts are subjected to objective reflection, one’s emotions, behaviour and physiological reaction generally change (Beck, 2011). In this process, sometimes themes pop up like low self-esteem or passive communication style. These can then be trained. Training them involves behavioural activation. That is, in other words, “fake it ‘till you make it”. By changing one’s behaviour, emotions and thoughts can also start changing in a positive direction. There are methods to encourage patients to change their behaviours positively. In many ways, these methods are not very different from those used by elite athletes and peak performance individuals. 

CBT is about getting you from point A to point B. Have you not experienced in your life a time when changing the way you looked at something completely changed the outcome?

Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). Guilford Press