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What is Cognitive Behavioral Therapy (CBT)?

The basic idea of CBT is that we can change our feelings by changing our thoughts. For example, you might feel sad or depressed after failing your driving test if you think "I'm a failure" or "now I'll never be able to drive." Those are examples of dysfunctional thoughts. "I'm a failure" is an example of over-generalization and personalization. "Now I'll never be able to drive" is an example of catastrophizing. Over-generalization, personalization and catastrophizing are types of dysfunctional thoughts, otherwise known as cognitive distortions.

In CBT, we look at dysfunctional thoughts and replace them with alternative thoughts. An alternative thought after failing the driving test might be "if I study harder next time, I can pass" or "now I have a better idea of what is required to pass, so I am more likely to pass next time." We might look at evidence for and against the dysfunctional thoughts, and the alternative thoughts. Your therapist might ask what percent do you believe the alternative thought, and what percent do you believe the dysfunctional thought. They don't have to add up to 100%! I usually invite my clients to imagine believing 100% in the alternative thought that they came up with. How does that feel? In this example, you might feel hopeful or more confident.

Other ways that I use CBT include making a mood chart, to track sadness, happiness, anxiety or whatever it is that you want to change by coming to therapy. We look at activities and patterns that led to increases in happiness, or reductions in anxiety. For example, social time and exercise might result in feeling happier or less anxious. Getting more sleep and eating healthy food regularly might result in feeling less sadness.

Cognitive Behavioral Therapy (CBT) is based on an earlier type of therapy called Behavioral Therapy. Behavioral therapy includes exposures to things that might make you fearful, for example spiders, or large groups of people you don't know. The idea is that as you gradually learn that these things don't actually harm you, your fear or anxiety reaction is extinguished. Mindfulness or meditation can be used to stay calm before and during the exposures. Exposures can be done in your imagination, prior to or instead of doing them in real life. Mindfulness and imaginal exposures are examples of CBT.

Behavioral therapy grew out of our knowledge of conditioning, the study of animal training in a laboratory setting in the first half of the 20th Century. You might have heard of Pavlov's dog, trained to salivate to the sound of a bell that was initially rang before food was presented. Or a rat that learned to fear electric shocks paired with a light. Both of these are examples of Classical Conditioning, where a reflex response (salivation, fear) that is normally a response to a particular stimulus (food, pain) becomes a conditioned response, associated with a conditioned stimulus (bell, light). Gradually, as the conditioned stimulus (bell, light) is presented more and more times without the food or shock, the animal learns that the association is no longer valid, and the conditioned response diminishes. That is called extinction, and is the basis for exposure therapy.

You might also have heard of the Skinner Box, an experiment on training rats in the 1930's, to produce something called Operant Conditioning. The rat in the box learned to press a lever in order to get a food pellet reward, and continued pressing the lever even when this didn't always result in any food. (Sometimes the rat was given an electric shock when it didn't press the lever, but this actually didn't help it learn). Operant conditioning, the use of rewards to encourage and shape actions, is a big part of behavioral therapy and CBT. An example is making a list of rewards for yourself (like watching a funny show on TV, or eating a snack) and using them to promote those good habits that are otherwise hard to do (like going to the gym, or cleaning your room). The cognitive part here is thinking about and visualizing what's likely to happen. We don't know if the rats and dogs do that.

The cognitive part of CBT came from Aaron Beck's observation, in the 1960's and 70's, that his depressed patients often had a pattern of negative thoughts and beliefs, about themselves, the world and the future. He found that helping the patients examine these thoughts and beliefs and change them often resulted in the patients feeling better.

The practice of Mindfulness was a later addition that complements CBT. Mindfulness is the practice of observing one's thoughts and feelings, just noticing them come and go without necessarily judging or trying to change them.

What works best for you? You can try changing your beliefs when you notice dysfunctional thoughts pop into your mind, or simply observing the thoughts and feelings and noticing them come and go. Alternatively, do more of the things that make you feel happy, and less of the things that make you anxious or sad. Or tackle your fears by relaxing and then imagining your worst nightmare, and noticing that nothing bad really happens.

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