Cognitive Behavioral Therapy

Defined

Cognitive behavioral therapy (CBT) is one of the most effective psychotherapies available (Potter, 2020). It has succeeded in reducing the burden of a wide variety of mental disorders, including depression, anxiety, chronic pain, obsessive compulsive disorders, sleep problems, phobias, addictions and eating disorders (Torres, 2021).

At the root of this approach is a short term, goal oriented perspective focused on identifying, challenging and altering damaging patterns of thinking, maladaptive attitudes, and internally held beliefs that exacerbate symptoms. Once these patterns are identified, CBT offers a time constrained, paced series of mentation exercises that work to create more helpful thoughts that encourage more constructive behaviors (Potter, 2020).

CBT allows us to use our matured perspective to reassess the events of the past and objectively evaluate the origin story of the negative, harsh, and often unrealistic thoughts we developed about ourselves at a young age. This approach allows us to break apart such thoughts, and test their components against reality, leading to what is known as cognitive restructuring (Torres, 2021).

Through the act of cognitive restructuring, we can provide ourselves with a more accurate insight into the things we believe to be true about ourselves, thus developing neutral or positive ideas about who we really are. CBT creates a framework through which we can avoid the pitfalls set by our past mental blocks and habitual thinking, and discover new ways of approaching challenges that improve how we interpret and react to what happens around us (Torres, 2021).

Behavioral activation is an important component of CBT, and it involves identifying behaviors, thoughts and experiences that we enjoy. These activities should be prioritized to enhance feelings of empowerment, optimism, and happiness (Wheeler, 2022).

People who engage in CBT have been shown to experience physical changes to the structures of the brain responsible for information processing and behavioral/emotional responses. In fact, CBT has been shown to be equally as effective as the use of medication alone (Potter, 2020). It has been shown that CBT can be effective when completed without the direct oversight of a therapist, and that the impact of such self-help efforts can be long lasting (Gillihan, 2013). So much so, that 75 months after engaging in CBT therapy, people continued to report signs of improvement (Torres, 2021).

CBT comes in many forms, and can be skillfully tailored by a mental health professional to meet the needs of each individual based on the specific challenges they are facing. The CBT methodology presented here is a generalized adaptation of the key points from a trauma-focused approach (HCSAT, 2011) and a depression-focused approach (Rosselló, 2007).

Before Getting Started

When we start to break down our unhelpful thinking patterns - negative, painful and difficult-to-manage emotions may arise. Some of these emotions may surprise or scare us, and some may change the way we think about ourselves and others. While this may be unpleasant at first, these changes in perspective are the goal of CBT. We are integrating past experiences into our identity to allow us to move forward in other areas.

Making space to feel difficult emotions allows us to gain perspective on them. New perspectives are at the foundation of acceptance. This CBT effort asks that we make time each week to engage these exercises, and choose a safe, private place to physically do the work. One where its okay to express whatever comes up openly.

Pick a time that is later in the day when other commitments are completed, but not so late that its time to attempt to sleep afterwards. Work up to the exercises by making a soothing drink, getting wrapped up in a warm blanket or asking a supportive person or pet to sit nearby.

Cool down after the exercises by taking a shower, going for a walk or eating a favorite snack. Acknowledge that emotions will be heightened and sensitive, so take the time needed to recover. Do not make any big decisions or engage in a fight, argument or other unpleasant social situation immediately after these exercises.

When new emotions are allowed to surface, it can be hard to identify them at first. Visit the emotions list often, and try to use the most descriptive language possible when describing what comes up in CBT. This will allow us to more honestly connect with ourselves and make our time and effort more meaningful. For access to the emotion list, click here.

Strategy Overview

Here, we're going to explore the tool of CBT through an informational lens to gain insight into how the many different forms of CBT can work for us. We'll use 10 separate worksheets to break up CBT into a series of mentation exercises. One of these exercises usually takes between one to two hours, and one exercise is recommended per week.

Do not push through these exercises too quickly. It takes time to openly and honestly digest the material provided and the thoughts and feelings that arise. Too much at once can generate overwhelming thoughts and feelings, emotional burnout, suffering and distress.

Do not postpone exercises or stop part way through and give up. Early exercises in this strategy involve identifying painful thoughts and emotions, and this can feel intimidating, discouraging and scary. However, it is the later exercises where the healing of those painful thoughts takes place. If we don't complete the series, emotional pain will linger since we haven't discovered the tools needed to resolve it.

CBT is aided by the use of a journal that can help track the thoughts that come up during the mentation exercises (Potter, 2020). It can be helpful to print out the worksheets below, copy/paste the content into an editable online document, or use pen and paper to write down the exercises and our responses to them.

Worksheet One - Selecting a Starting Point

First we identify an event of the past that we feel injured or hurt us (HCSAT, 2011). Ideally, this will be one that often comes to mind and brings with it unpleasant thoughts and feelings.

Next, we write approximately 200 words about the who, what, when, where, why and how of the event. The goal here is to write about what surrounded the event and made it possible. What caused this event? What caused it to be impactful for us?

Now, we will write another 200 words about what we've thought about the event since it occurred. What beliefs about the event do we have? What beliefs about ourselves, about others, and about the world have developed since the event?

Try to be clear, concise, realistic and as factual as possible.

Worksheet Two - Identifying Stuck Points

A stuck point is a habitual, conflicting thought that creates a strong, unpleasant emotion. This unpleasant emotion goes on to encourage us to engage in unhealthy or problematic behavior as we attempt to soothe ourselves (HCSAT, 2011). Stuck points create roadblocks to recovery because they keep our focus on the harsh, negative aspects of what happened and cause us to ignore the positive or neutral aspects of the event. Thus we remain ‘stuck’ is a frame of mind that does not allow us to heal (USU, 2020).

Stuck points sometimes appear together, and need to be broken up for the sake of clarity. For example, the statement 'I should have known better, it's my fault this happened' is actually two separate stuck points. If we’re having trouble verbalizing our stuck point, we can consider putting it into an If/Then statement. For example, 'If I had done more to prepare for the event, then I would have known better.' (USU, 2020).

Stuck points often use extreme and inflexible language that convey a sense of black/white thinking or total ownership of what happened during the event. Words like ‘always’ and ‘never’ and ideas like ‘its all my fault’ and ‘I deserve/don’t deserve’ often come up in stuck points. Sometimes we use language that has more than one meaning, which makes our statement vague and leads to unhelpful or confusing assumptions (USU, 2020).

Stuck points come in two forms, assimilated and over-accommodated (USU, 2020):

Assimilated stuck points reference how we should have, or could have, acted to alter the course of the event. Thoughts like ‘It's my fault it happened’ or ‘If only I had acted differently’, or ‘I wish I knew then what I know now’.
Over-accommodated stuck points are focused on how we will perceive what happens to us, and how we will act, in the present or in the future. Examples include ‘Others cannot be trusted to care about me.’, ‘Those in authority are inherently unsafe.', and ‘I need to use force to protect myself in the future.’

Examples of stuck points include (USU, 2020):

I am unlovable/damaged/worthless/powerless/permanently broken/a bad person
I don’t deserve to live/be happy/be loved/be safe/be healthy
If I had/hadn’t done X, Y would not have happened
Its my fault that X occurred
I will never let someone hurt me like that again
My happiness today invalidates the suffering of the past

Stuck points are not meant to describe specific behaviors, feelings, morals, questions or facts. They are thoughts and beliefs about ourselves and the world. If we find ourselves thinking of behaviors or feelings when trying to identify a stuck point, we can instead what we believe to be true about why the behavior, feeling, etc has occurred (HCSAT, 2011).

There may be one or many stuck points related to the event from Worksheet One. Using concise, specific language - describe everything that comes up when thinking about the chosen event.

Worksheet Three - Identifying Emotions

Lets now enhance the language used in the previous exercise by using an A-B-C worksheet. ‘A’ stands for activating event, which came from Worksheet One. 'B' is a belief or stuck point from Worksheet Two. 'C', or consequence, is the emotional impact of the unhelpful thought. Be as accurate and descriptive of the feelings as possible (HCSAT, 2011). Click here for a detailed emotions list.

Activating Event (Something happened that triggered a strong reaction from me)

Belief/Stuck Point (My strong reaction put into words)

Consequence (What emotions and beliefs my stuck point generates)

While completing this worksheet, additional stuck points may come up. Write down what is brought to mind, and try to associate it with other, connected, thoughts or emotions.

Worksheet Four - Disputing Stuck Points

Let's now analyze each stuck point using objectivity and critical-thinking.

Draw a medium-sized circle. Next to it, list the names of everyone who was involved in the event from Worksheet One. Our name goes at the end. Include people who had influence over the event and the conditions surrounding it, even if neither were present at the time. Include environmental factors like traffic or weather, and physical factors like ailments or time constraints.

Use the circle to make a pie chart of who and what holds each percentage of the responsibility for causing the event to occur. Be realistic about assigning percentages. The goal here is to assign ourselves only what responsibility is left over after each other factor has been assigned its fair share. This process is considered to be a form of reality testing.

Another form of reality testing involves us asking ourselves a series of questions to better ground our past experience in our present, more grown and matured, perspective. Here we consider honestly, and without passing judgment on ourselves or others (HCSAT, 2011):

Did I jump to conclusions at any point?
Did I try to predict the future?
Did I exaggerate aspects of what happened?
Did I minimize aspects of what happened?
Did I ignore certain parts of the event altogether?
Did I oversimplify things as right/wrong or good/bad?
Did I overgeneralize one event into a pattern of events?
Did I assume the thoughts and intentions of others?
Did I use how I felt about the event as proof that my perspective was correct?
What facts of the event dispute my interpretation?

Now we're going to reinforce our adult perspective against the perspective of the past by talking back to each stuck point as if defending ourselves against it. Challenge each stuck point in every possible way. List every reason to invalidate it. Write a more neutral phrase to replace each stuck point. (Rosselló, 2007).

Next, we'll take a step back and use a third person perspective on challenging our stuck points. Imagine a loved and respected friend has written these stuck points about themselves. What could we say to them to help them see themselves more positively? What would we say if we had to defend a loved one from someone using one of our stuck points against them (HCSAT, 2011)?

Worksheet Five - Developing Flexible Thinking

Stuck points are a form of inflexible, habitual thinking that we use to categorize events as good/bad or right/wrong. This is a lens that tends to reflect what we expect to see, not necessarily what is really there (Hendrix, 2016).

Life is complicated and constantly changing, so a one-size-fits-all approach to problem solving can limit what is possible. Stuck thinking makes it difficult for us to interpret grey areas, subtly, and nuances of language. It hinders our ability to identify the true motives and intentions of others (Hendrix, 2016).

Flexible thinking allows us to become more adaptable to changing situations, both mentally and through our behavior. It allows us to more accurately assess our surroundings, the motivations and needs of the people present, and the tools available to us to act on. This form of flexibility helps us problem solve and work with others as a part of a team more effectively (Hendrix, 2016).

Let's now review the stuck points, and identify areas where we are using inflexible thinking. To do so, we take a piece of paper and draw a line down the middle. On the left side, write down each of the stuck points. Then, take a marker or pen and underline or highlight the words within each stuck point that show inflexible thinking.

Look out for keywords like ‘always’, ‘never’, ‘constantly’, ‘nothing/none’, ‘can’t’, ‘should/shouldn’t’ and any synonyms. Identify phrases that describe things as permanent, concrete, or rigid and language that is harsh, critical, insulting or demeaning. Also look out for any judgmental language or language that is destructive to self-image (Rosselló, 2007).

On the right side of the page, let's now rewrite each stuck point into a flexible thought that can be applied to a wider variety of situations. This new sentence will be longer, will be future focused, and will benefit from the inclusion of non-judgmental and constructive language (Rosselló, 2007).

Try out replacing the words and phrases underlined with antonyms (opposite words). Rework harsh language into more neutral or positive language. Instead of permanent and concrete language, incorporate the use of change words like ‘sometimes’ or ‘on occasion’. Reword the stuck point using a verb (action word) that generates a sense of power, for example ‘When X happens, I can…’, or ‘There are times when I am unsafe, and when that happens, I will…’ (Rosselló, 2007).

Examples include:

‘I never get what I want’ ------> ‘Sometimes things don’t go my way, and I can manage myself during those times’
‘I can’t do anything right’ ------> ‘I’m not perfect all the time, and I don’t need to be’
‘The world is out to get me’ ------> ‘Bad things might happen to me, but that doesn’t mean I am bad’

Worksheet Six - ABC &D &F

Let's combine the work we've done so far and break down stuck points as they arise in daily life.

For one week, evaluate an activating event from each day using the summary table shown on the CBT page and (D)ispute any stuck points that have been previously explored and any that are new. Then, use (F)lexible thinking to rewrite those stuck points.

Activating Event (Something happened that triggered a strong reaction from me)

Belief/Stuck Point (My strong reaction put into words)

Consequence (What emotions and beliefs my stuck point generates)

Dispute (Challenge my stuck point using neutral or positive alternative thoughts)

Flexibility (Rewrite my stuck point into a more flexible statement that can apply to more situations.

Worksheet Seven - Stopping a Stuck Point

Now its time to create beneficial ways of thinking about ourselves and our world.

Here we apply the principle of radical acceptance. This perspective asks us to make an active effort to accept people as they are, the situation for what it is, and ourselves as imperfect human people with strengths and weaknesses. For more on radical acceptance, click here.

For one week, make room for each stuck point that comes up in day-to-day life. Let it exist as it is, and try to accept that it came up without allowing a larger emotional response to develop. This reduces the impact of stuck points on our mood and perspective, and diminishes their impact on our behavior over time. When a stuck point arises, take the following actions (Rosselló, 2007):

Interrupt the thought as quickly as possible by saying the word ‘stop’, clapping or snapping a rubber band.
Stop all movement, close our eyes, and place our hands at our sides.
Take a deep breath in for four seconds, hold for four seconds, then exhale for four seconds. Repeat times five.
Congratulate ourselves for identifying a stuck point as it came up and stopping it from gaining momentum.
Locate any tension in our body and release it.
Repeat an affirmation we’ve made (click here for help on affirmations) or repeat a positive phrase from the list below:

I am intelligent.
I am responsible.
I am a decent person.
I am doing a good job.
I am in control of myself.
I can do better next time.
I have a right to be happy.
I am learning to be happy.
I am honest and trustworthy.
I am hopeful about my future.
I handled this situation reasonably.
It is a beautiful morning/day/evening.
I am deserving of recognition and credit.
I can handle a crisis as well as anyone else.
I am able to provide for myself and my family.
My experiences have prepared me for the future.
I can find the strength to solve difficult problems.
I can choose the best solution to difficult problems.
Even though things are bad now, they can get better.
I can learn from the past, and not repeat my mistakes.

Its important that we take some time at this point to remind ourselves that by virtue of being alive today, we know for a fact that we kept ourselves safe in the past. This means that, while we cannot predict the future, we can have confidence that we are able to take actions to survive what will come (Rosselló, 2007).

Given how heavy the workload has been so far, we can benefit from using humor to reduce the tension caused by our stuck point and lighten our mood. For more information on humor, click here.

Often times our harsh thinking can cause tension in both body and mind. If this is the case, consider using physicality to reduce that tension. Information on physicality is available by clicking here.

Worksheet Eight - Activating the Reward Center

Let's now consider the activities that make our life fun and meaningful. These pleasant activities do not have to be out-of-the-ordinary to be rewarding. Surfing a favorite website, eating a healthy, tasty snack, or talking on the phone with someone we like all fall into this category.

Start by thinking about times that were the happiest, the calmest, or felt the safest. Who was there? Where was it? What do we remember most vividly? How did we feel at that time (click here for emotions list)? What thoughts did we have that improved how we felt during those times? Were there times we thought we wouldn’t enjoy an event and it turned out we did? Try to be as descriptive as possible (Rosselló, 2007).

For one week, identify all the tasks enjoyed each day and tally up how often you engage in each one. Every little task counts, including showers and playing with pets and friends. The goal here is to identify what matters to us so we can prioritize those tasks and maximize the positive emotions that come with them. Ideas include crafting, making plans, shopping, driving, being outside, religious services, organizing, playing a game, meditating, exercising, singing, traveling, taking pictures, helping others, giving gifts, taking a bath, and eating good food (Rosselló, 2007).

Add up the number of tally marks from the week. The goal for the next week is to do at least the same number of positive activities, but ideally - one more. Those of us with a high number of other commitments and time constraints may find this task exhausting, but this effort can make more room in our life for what gives us energy (Rosselló, 2007).

To maximize weekly reward chemicals, consider using a calendar or a chart to help block out certain windows of time for joyful activities. Commit to those time frames and set boundaries with others who may ask for something during that window (Rosselló, 2007). For help setting boundaries, click here.

Worksheet Nine - Goal Setting

Let’s grow our newly developed understanding of ourselves into short term, long term, and lifetime goals. This future-oriented mindset will allow us to reduce the influence of the past as we grow into the type of person that we want to be. Short-term goals should be achievable within six months, long term goals may take years, and lifetime goals involve how we see ourselves aging and the type of person we hope to become (Rosselló, 2007).

The most effective goals are described as SMART. We can consider the following when setting our goals (SAMHSA, 2021):

Specific - Who will be involved? Where and when will it take place? What materials are needed?
Measurable - How do we know when the goal is accomplished?
Attainable - Can it realistically be done?
Relevant - Does this goal align with my larger efforts?
Time Constrained - How long will it take to complete?

Try to write at least two short term, two long term, and two life time goals this week.

Worksheet Ten - Congratulating Our Progress

Now we're going to take a moment to celebrate the hard work we’ve put into this process. Completing the worksheets above was not easy, and now we know that we are capable of flexibility, change and positivity.

Let's make an effort to congratulate ourselves at least once a day, every day, even if we feel like we may have not made much progress. Celebrating ourselves and the efforts made make it easier to keep going (Rosselló, 2007).

Others may not recognize the changes we’ve made, and that’s okay. The only thing that matters is that WE recognize our own effort and make time to acknowledge that we’re on a path toward improving how we experience the world around us.