Tips, Ideas & Recommendations in CBT Treatment

​Anxiety and fear are quite different. To illustrate the difference I normally share a concrete example. Let's say I open my front door and there is a wild tiger right there. I will be terribly afraid. There is a clear and imminent danger I can pinpoint, thus leading to the fear. However, if I step out of my front door, hear a noise or see some movement in the grass, and think that there might be a tiger in there somewhere, odds are I will be feeling quite anxious. I think there might be a threat somewhere, only I cannot see it. I can imagine it.
 
Anxiety is a response to perceived threats that come to us either in the form of thoughts (a story) or images. Because we don’t like the feeling of anxiety, we often avoid thinking about those threats and try to block out the troublesome images. This helps reduce the anxiety in the immediate short-term. But long-term, it is still there. That pesky feeling of foreboding, a tightness in your chest, a lump in your throat.  If it’s in your head and it has a negative emotional valence, it will come back at some point. That makes sense, right? I’s your brain trying to keep you safe by reminding you often of the dangers around you.
 
How can you conquer that anxiety? There are several methods in cognitive behavioral therapy (CBT) for anxiety treatment. The most effective one is exposure therapy. This is an approach where, figuratively,  you get out of the house, go to where the noises and movement in the grass are, look behind the bushes, and find out that there isn’t a tiger there after all – it’s a kitty cat. To get to this liberating a-ha moment, we do need the courage to be willing to face the tiger.
 
For some types of anxiety such as driving or public speaking, we can actually go out there and do exposure exercises in real life relatively simply. But other times, if our fears involve imagined situations and outcomes that we can’t replicate in the real world, then we have to use the tool of ‘imaginal exposure.’ Imaginal exposure, as the name suggests, involves immersing ourselves in this worst-case scenario fear of how things can turn out badly. For example, if I am constantly anxious about having a deadly disease, I can enter a mental world where that actually happens. If I am concerned about my children having a terrible accident, I can make that true in my head.

​Imaginal exposure scripts are short stories that we can write laying out what would happen if our worst fears came true. We add what happens in the immediate aftermath and what happens over the long run. These scripts are usually sad and dark because, well, our anxieties are sad and dark. Once an anxiety-provoking imaginal exposure script is written, exposure therapy involves reading that script over and over and over, several times a day for several days, recording the level of distress that it brings up. The objective is to get you habituated to the facts and feelings in the script.  After reading a story a few hundred times, it gets boring. Boring is the opposite of anxiety-provoking. Boring is good.
 
Of course, you’ll be well served to have a therapist support you through this unpleasant but highly effective and necessary process. Any well-trained CBT therapist should be able to hold your hand and help you feel safe and cared for as you go face your tigers. Happy hunting!

Cognitive behavioral therapy (CBT) tends to operate within a much more short-term, focused model of psychological intervention that aims to reduce current symptoms, address specific problems, and build skills that the client can take with him/her after treatment ends. Hence, treatment length is usually measured in weeks or months, rather than years or decades.

​Indeed, there is ample research evidence that response to psychotherapy follows a 'negatively accelerated' curve where more and more effort is required to achieve smaller and smaller changes (that is called a log-normal curve for the math geeks out there). Dr. Ken Howard was the first to analyze this correlation and posit markers for response to psychotherapy according to dosage. Here is his original article.

The original dose-effect study was run in 1986, based on psychodynamic or interpersonal treatment only, with the following findings:
* About 15% of patients improve before the first session of therapy 
* 50% of patients typically improve at 8 sessions
* 75% of patients typically improve at 26 sessions
* 85% of patients typically improve at 52 sessions

It is possible that modern psychological techniques have accelerated that theoretical curve in the past 30 years. In practice, however, there are many factors influencing the right dose of psychotherapy for each client, including diagnosis, acuity, readiness to change, social circumstances, and frequency of treatment (more regular treatment is  shown to be more effective).  But what we can glean from the data above is that longer and longer treatment periods may indeed offer diminishing gains at increasing levels of effort. 

With CBT, you and your therapist will have powerful tools for change readily available. The specific length of psychotherapy treatment will vary for each person and each presenting problem. But with commitment and focus in the context of a true partnership, CBT can lead to fast and meaningful change.

Often times, thoughts that are largely accurate or even innocuous at the surface level can lead to intense sadness, anxiety or anger. For example, telling myself that “this meat tastes bad” or “I fumbled that word” or “she is not paying attention” can quickly result in a drastic mood change.

In CBT, the downward arrow technique is a way of working through these automatic thoughts to find the irrational beliefs at the base of them that are triggering the strong emotions. These beliefs may not be immediately obvious to us, so we need to ask the same questions repeatedly until we get to the bottom of it: “what does that mean about me?” and “why is it upsetting to me?”.

​When we get to the end of the chain, we will find a deep-seated – and mostly unhelpful – belief that explains where these intense feelings are coming from. That is called a “core belief” or “schema” and commonly builds on themes of incompetence or failure, abandonment or unlovability, and helplessness. Once these schemas are identified, we can challenge them using CBT techniques similar to the ones applied to automatic negative thoughts.
 
Examples of Downward Arrow technique:

1) This meat tastes bad
And if that were true, what would that mean about you? Why is it upsetting to you?
-->
I am a terrible cook
And if that were true, what would that mean about you? Why is it upsetting to you?
-->
I am a bad mother
And if that were true, what would that mean about you? Why is it upsetting to you?
-->
I am a complete failure
 
2) I fumbled that word
And if that were true, what would that mean about you? Why is it upsetting to you?
-->
I didn’t do everything perfectly
And if that were true, what would that mean about you? Why is it upsetting to you?
-->
People will be disappointed in me
And if that were true, what would that mean about you? Why is it upsetting to you?
-->
I will be alone forever
And if that were true, what would that mean about you? Why is it upsetting to you?
-->
I am unlovable

3) She is not paying attention
And if that were true, what would that mean about you? Why is it upsetting to you?
-->
She doesn’t care about me
And if that were true, what would that mean about you? Why is it upsetting to you?
-->
Nothing I do can make things better
And if that were true, what would that mean about you? Why is it upsetting to you?
-->
I am helpless

With good CBT techniques, you can identify your schemas and change them over time.

How do we interpret the events that happen in our lives?  Cognitive theory can help us get a better understanding of how that happens. The first concepts that you want to familiarize yourself with are 'assimilation' and 'accommodation.' Charlotte Nickersen wrote a very informative - and well illustrated - article with a simple overview of these concept.s 

When individuals are confronted with new information that is inconsistent with preexisting schemas (i.e., stored bodies of knowledge), one of two processes occurs: assimilation or accommodation. Assimilation is the incorporation or alteration of new information to fit into existing schemas. Accommodation is the modification of existing schemas (and creation of new ones) to incorporate new events and information.  

Although accommodation is necessary to integrate a new experience, individuals sometimes over-accommodate when interpreting input in their environment. Over-accommodation occurs when schema changes are inaccurate and overgeneralized.

Assimilation is interpreting incoming information in light of prior beliefs:

• I believe that leaving my car in a dark parking garage in a high-crime neighborhood is dangerous. I do that one day, and my car is broken into. I can easily understand this event within my existing schemas, so it would be assimilated with no adjustment of beliefs needed.
• Growing up, I was taught to believe that “good things happen to good people and bad things happen to bad people” (also known as a “just world” hypothesis). Then something bad happens to me. To assimilate this event within my schemas, I would then need to tell myself that I must be “bad.”

Accommodation is altering beliefs enough to incorporate the new information:

• Growing up, I was taught to believe that “good things happen to good people and bad things happen to bad people.” Then something bad happens to me. I can accommodate that by finding a new equilibrium in my belief system that states that good and bad things happen to both “good” and “bad” people – the world is not always “fair”.

Over-accommodation is altering one’s beliefs about oneself and the world to the extreme in order to make sense of new events and information. Examples of over-accommodation (also known as over-generalization) in the situations above would be:

• I am not safe anywhere.
• Since I can’t control what happens to me, what I do and don’t do doesn’t matter al all.

One of the goals of CBT is to help you stay away from over-accommodations (and unhelpful assimilations) and find accommodations that are complete, balanced, and useful to you.

If you’re looking for a therapist and getting confused about what those letters after their names mean, you’re not alone. There are a number of licenses in California that allow a provider to offer psychotherapy services to individuals, couples and families. All of them have to do with the kind and level of courses taken in school. Here is a quick (and non-exhaustive) cheat sheet.
 
First, know that all therapists in California must have a graduate degree, supervised clinical experience, and a State license (that is regularly renewed) in order to serve the public. Individuals with only an undergraduate degree cannot be licensed to provide psychotherapy. Within graduate programs, here are some common credentials that you may find. All of them can offer individual, couple’s, family, or group therapy.
 
Doctoral Level
1) PhD: Clinical Psychologists
These are professionals who have completed usually five to six years of graduate training, a research-based dissertation in clinical psychology, plus one year of post-doctoral training after graduation before getting licensed.
2) PsyD: Clinical Psychologists
Similar to PhDs, PsyD credentials are doctorate degrees in Psychology that follow the same pre- and post-doctoral training, with a lower emphasis in primary research during graduate school.
3) MD: Psychiatrists
These are medical doctors who have completed medical school and a specialized residency of four years in mental health. Psychiatrists are the only mental health providers on this list who can prescribe medications in California. Many of them also offer psychotherapy services, although it is not the main emphasis of most programs currently.
 
Master’s Level
4) MFT (or LMFT): Marriage and Family Therapists
These are therapists who have completed typically two years of graduate level courses, obtaining a Master’s degree in a mental health-related area, followed by two years or more of supervised practice before getting licensed.
5) LCSW: Licensed Clinical Social Workers
These processionals have attended graduate school in Social Work typically for two years, obtaining a Master’s degree in Social Work, followed by two years or more of supervised practice before getting licensed to provide counseling.
6) LPCC: Licensed Professional Clinical Counselor
This is a relatively new credential in California, but is similar to the ones above. These processionals have attended graduate school typically for two years, obtaining a Master’s degree in Counseling, followed by two years or more of supervised practice before getting licensed.
 
You can learn a bit more about the differences across these Master’s levels clinicians here.
 
Unlicensed Professionals/Professionals in Training
As you saw above, all mental health professionals will practice for a number of years under someone else’s supervision in order to accrue experience and develop expertise in psychotherapy. While these individuals are in training, you may meet them under the following credentials:
7) Psychology pre-doctoral intern (pre-doctoral degree, pre-licensure)
8) Psychology post-doctoral fellow or resident (post-doctoral degree, pre-licensure)
9) ASW: Associate Social Worker (post-master's degree, pre-licensure)
10) MFTi: MFT intern (post-master's degree, pre-licensure)
 
Each one of these professions is regulated by a different Board in the State of California; for example, psychology practice is overseen by the California Board of Psychology whereas MFTs practice according to the regulations of the Board of Behavioral Sciences.
 
You may find the best therapist for you at any of these training levels. Ultimately, you should be looking for someone with whom you connect, who helps you identify actionable treatment goals, and who helps you get there by combining the science of evidence-based treatments with the art of human relations.

I recently re-read a classic article by Dr. Albert Ellis, inventor of Rational Emotive Therapy (RET) and one of the early practitioners of cognitive therapy, that presents a valuable take on the causes of emotional suffering. I’ll save you a dozen pages of technical reading and summarize it here. All of emotional suffering in the human race comes from us conflating ‘needs’ and ‘wants.’ Let me explain.
 
Each of us has a series of goals for ourselves and our lives. Ironically, as social beings, they are not that different across people. Generally, we want safety, approval, achievement, efficacy, comfort, and happiness. These are laudable desires: they help us survive, thrive, and procreate. When faced with situations where we fall short of these goals, it is natural to feel disappointed, upset, sad, or frustrated. These appropriate negative feelings help us cope with life and direct our energy towards change. They do not keep us stuck.
 
However, consciously or unconsciously, many of us often escalate these ‘wants’ into ‘needs.’ Beyond wanting safety, we may start expecting that under all conditions and at all times, so we don’t suffer discomfort, pain, or handicaps. We may not only want approval, we may require agreement, admiration, and love by all our significant others. Rather than merely wanting achievement, we may start believing that we need to be notable, celebrated, and special.
 
Naturally, when those rigid ‘needs’ are not met, we suffer. But this suffering is more acute and persistent, because it is violating an existential condition (mind you, one that we invented ourselves). Worse, when we notice that we are stressed, anxious or depressed in response to certain events where our ‘needs’ are unmet, more suffering ensues as we continue to judge the situation as unbearable or ourselves as incorrigible. That keeps us stuck.
 
For example, let’s say that I want achievement. Through a process of illogical thinking, I escalate that into the irrational belief that I must have success and happiness in my life at most times. As a nice bonus, that will guarantee that I am worthwhile. Then an outside event that I cannot control happens that leads to failure and an understandable state of sadness. Because this threatens my ‘need’ (and my worthwhileness), the sadness grows into despair and into depression. And then, when I realize that I am depressed (and unworthy), I feel depressed about my depression. I may even feel depressed for feeling depressed about my depression, as all of those things violate my achievement and happiness ‘needs.’
 
In contrast, if I can stay in a space where I am thinking logically about my desires and longings, I can interpret my setbacks for what they are: unlucky, unforeseeable, or unfavorable steps in a long journey. Ellis suggests that I tell myself something along these lines: “I don't like failing or experiencing losses. I wish that my life was richer and more comfortable. But if I am thwarted, do fail, get rejected, and am uncomfortable at Point A, that is unfortunate but hardly the end of the world. I can still lead a fairly happy life. Now let me go back to the immediate events and try to improve or deal with them so that I can get more of my goals fulfilled at Point B." That’s neat, isn’t it?
 
As you can see, Ellis was laying the groundwork for much of the Cognitive Therapy fundamentals that followed him.  With the help of a good CBT book or an individual therapist, you can learn to identify which of your ‘wants’ has serendipitously morphed into a ‘need’ that may be keeping you stuck right now.

How do you define competence? Your answer to this seemingly simple question can have a large impact on how you interpret your academic and professional achievements and how satisfied you feel about them. Some views of competence can be particularly detrimental to your emotional well-being, so it’s worth watching out for them.
 
Dr. Valerie Young has described five unhelpful “competence types”: views of what defines aptitude and proficiency that actually hold us back. They are:
 
1-The Perfectionist: in this view, competence is defined by “how” things are done. If they are 100% correct, 100% of the time, then you’re competent. Any small deviation from that equals total defeat. And since it’s impossible to get everything right all of the time, you are often aware of your misses and the distress that accompanies them in the form of self-doubt, worry, or shame.

2-The Natural Genius: here, competence is defined by “when” things are done right. For the Natural Geniuses out there, being competent means getting it right the first time, and doing it naturally, effortlessly, and immediately. This is the view that talent is congenital and you either have it or not. If you don’t get it right on the first time or struggle to master a skill or project, then you’re actually not that competent. That’s a huge disappointment.

3-The Soloist:  This is the “who” view of competence, in which it equals the ability to perform tasks independently at all times. If you need help, you are incompetent, so you might as well take on immense mountains of work to do all by yourself. When you struggle or get stuck, feelings of failure, shame or defeat follow.

4-The Expert: The focus of competence for the Expert is in “what”. If you are competent in this definition, then you know everything there is to know about a task, challenge, or project even before you start. You fear being exposed as ignorant or inexperienced, so you spend inordinate amounts of time getting better educated, more informed, and more deeply acquainted with whatever topic is at hands; often times, at the expense of actually getting stuff done.

5-The Superhuman: For this type, competence is measured in throughput. It parallels how many roles you can juggle, how many projects you can deliver, how often you volunteer, or how much time you spend on turbocharge, doing more than everyone else around you. This overload can lead to many short-term accomplishments, at the cost of long-term stress and burn out.
 
Do you see yourself in any of the types above? If so, how has this definition of competence served you over time? If the answer is not that well, then you can start working on changing it. You can do that with the help of a CBT therapist by first understanding your current belief system, then challenging assumptions that are unhelpful, and finally building new ones that are more realistic, take into account several viewpoints, are more complete, and help you truly succeed in the long-term.

Many mothers - both those staying-at-home with the kids as well as those working out of the house - often struggle with "mom guilt." Those are nagging feelings of guilt, shame, sadness, anger and despair that may be temporary or pretty pervasive. They are difficult and unpleasant. Older parents will tell you to let go, to enjoy the journey as time flies: "they grow up so fast." And yet, day to day those pesky feelings pop up, sometimes on cue and many times unannounced. 

Cognitive theory will tell you that those unwelcome emotions stem from your thoughts, the stories that you tell yourself in your head. It can be a thought that you may not be doing enough, a notion that you are not sacrificing enough, or just a belief that you are not getting things right while everyone else has it together. In terms of concrete thoughts, they might span the range from "I should be playing with the kids right now (as opposed to doing something else I also enjoy!)", "they are watching too much TV", "I shouldn't loose my cool", "I actually want to complete this work assignment but feel I should be spending more time with the kids." 

If you can't change your reality short-term, how can you deal with these thoughts and feelings more effectively? First, if I offer you a magic button that would make all of those beliefs and reactions go away, consider whether you'd press the magic button. It sounds like a good deal, right? Yet, these negative thoughts and feelings tell us a lot of beautiful things about you...They show you care, you want to do what is right by your children, that you are willing to look at your choices critically, and that you have really high standards and goals for yourself. All of those things are good!

Rather than pressing the magic button and make the "mom guilt" disappear altogether, how about figuring out how to modulate it? You can find a way to hold on to some of the healthy aspects of the guilt - after all, wanting to be the best mom you can be is an awesome goal! - but it is not so high that takes away from your chance to enjoy your children and your limited time with them. That is very doable with CBT.

To get to this lower level of distress, you will need to revisit the stories that you are telling yourself in your head. In CBT, we embrace the idea that your thoughts drive your emotions. Change your thoughts, change your emotions. There are a myriad techniques to re-write the automatic thoughts and ideas in your head around your parenting choices. You can learn about them in CBT-driven books such as Dr. David Burns' new Feeling Great book. Or you can work with a CBT therapist who can guide you in understanding and applying these techniques to the specific circumstances in your life. Your family will thank you!

Dr. David Burns is a world renowned psychiatrist and one of the pioneers in the development of Cognitive Behavioral Therapy. In the past decades, Dr. Burns has been focusing on advancing the clinical applications of CBT through a new therapeutic approach that he calls TEAM-CBT. You can read more about the elements of TEAM-CBT in one of my early blog posts or on Dr. Burns website.

TEAM-CBT is a framework for delivering evidence-based interventions in psychotherapy (and evidence-based here means techniques that have been corroborated as effective by rigorous scientific research). It combines Routine Outcome Monitoring, Motivational Enhancement, and CBT Methods with a strong focus on empathy and rapport building to deliver meaningful symptom reduction in fast periods of time. Indeed, in his current clinical work, which revolves mostly around training of therapists and professional workshops, Dr. Burns has, on many occasions, observed that individuals who had been struggling with depression or anxiety for years can experience near complete recovery in just a few hours.

To explain how that can happen, and provide more background and perspective on the TEAM-CBT approach, Dr. Burns was interviewed by one of our colleagues, Lisa Kelley. The transcript of the interview is an excellent primer to learn more about this powerful new modality. Here it is:

As a Level 5 Certified TEAM-CBT trainer and Master Therapist, I would be delighted to help you learn more about these tools to to enhance your life or, if you are a health care provider, to revolutionize your clinical practice!