Cognitive Behavioral Therapy (CBT)

People with anxiety disorders have many options to consider when they feel therapy is needed in their lives. You've learned about the basic concepts and practices behind cognitive therapy (your thought patterns exacerbate anxiety symptoms) and behavioral therapy (your behaviors reinforce anxiety symptoms). CBT is an integrative therapy which combines aspects of each of these therapeutic schools.

During CBT sessions, a person with anxiety will learn how to recognize and restructure his or her thinking as well as techniques to alter approach/avoidance patterns of behavior. CBT has been proven useful in addressing all of the anxiety disorders covered in this course. A typical CBT program lasts between 12 and 16 weeks, though adapting many of its exercises and self-reporting structures into your own life with anxiety can be a great step toward coping.

What to Expect from CBT

Cognitive Behavioral Therapy is a structured form of therapy that is generally divided into its major components:

• Cognitive component – A therapist works with clients to identify the self-defeating and self-triggering cycles of thought, worry, and anxiety in their lives. Self-talk, self-evaluation, and methods for dealing with cognitive distortions are typically addressed. This phase of the therapy is called functional analysis.

• Behavioral component – After teaching the cognitive aspects of anxiety, therapists help people develop exposure and desensitization programs to repeatedly, both mentally and in the real world, learn to cope and be present with the places and people that upset them. The foundations of behavior change and learning paradigms are brought to bear to a client's specific situation.

CBT argues that it is a person's typical and habitual patterns of thinking in conjunction with their repeated approach/avoidance behaviors which predisposes them to heightened anxiety and interferes with their powers to cope. Oftentimes simply being aware of a tendency or problem behavior is not enough to cure it (see Obsessive-Compulsive Disorder). CBT interventions address this gap; negative thinking is first pegged and then followed-through with everyday behavioral techniques.

Challenging Thoughts/Assumptions

We've already addressed the basics of cognitive therapy. Here is an extended breakdown of what the thought identification and reversal process (called cognitive restructuring) might look like for anxiety disorders:

• I.D. Negative Thinking – Anxiety disorders often blind people to their own irrational thoughts. A person with social phobia, for instance, may become used to imagining social interactions as terrifying to the extent that this feels like the truth instead of a distortion. CBT therapists help their patients bring these hidden thought patterns out into the open.

• Challenge Negative Thinking – Once the thought is out in the open, a CBT therapist provides tools for questioning, analyzing, and testing these anxiety-prompting ideas. We've gone over many of these techniques already, but some include purposefully conducting thought experiments and weighing the pros and cons of holding onto a belief.

• Replace Negative Thinking – The thought has now been exposed and challenged from many angles—the last step is to completely replace it with a neutral or positive version. This step may involve creating a short script of questions or directions to follow when the negative thought rears again. Here are some brief examples of this 3-part cognitive restructuring courtesy of HealthGuide.org:

Negative thought #1: What if I pass out on the subway?

Cognitive distortion: Predicting the worst

More realistic thought: I've never passed out before, so it's unlikely that I will on the subway.

Negative thought #2: If I pass out, it will be terrible!

Cognitive distortion: Blowing things out of proportion

More realistic thought: If I faint, I'll come to in a few moments. That's not so terrible.

Negative thought #3: People will think I'm crazy.

Cognitive distortion: Jumping to conclusions

More realistic thought: People are more likely to be concerned if I'm okay.

Creating an Exposure Hierarchy Program

Once you have practiced identifying, challenging, and replacing negative thinking, the behavioral component of CBT begins to take shape. With a revised mental toolkit for picking apart old habits of thought, you and your therapist may likely begin crafting an exposure program. The situations, memories, or places which prompt your negative thoughts will need to be approached either incrementally or all at once. The more you are exposed to the anxiety-provoking scenario, the more chances you have to cope with the physical symptoms of anxiety while actively addressing your thoughts in the moment.

Once common way to do this is through an anxiety hierarchy. If you suffer from Panic Disorder, for instance, it can be helpful to list out the places/events which provoke the most debilitating panic responses to the ones which provoke the least debilitating responses.

Gradually, you can begin to expose yourself to the least anxious situation, putting into practice your cognitive tools while simultaneously retraining/unlearning your fear response. This may begin with simple visualization exercises or even looking at pictures or videos. It could also begin in the physical world.

Once you can successfully and routinely visit that low-listed place or scenario, you and your therapist will move onto the next situation, and then the next. The great thing about hierarchies is that you have a systematic record of success to look back on for encouragement and support. Some CBT methods also advocate writing down your thoughts and feelings before, during, and after an exposure session. The more ways you monitor your progress, the more evidence you will have to prove your improvement.

The behavioral aspect of CBT may also involve secondary coping techniques such as breathing exercises and mindfulness/relaxation techniques. We go over these strategies more in-depth here.

Other CBT-based Therapies

There are several other behavioral variations which CBT therapists may advocate, including Acceptance and Commitment Therapy (ACT) and Dialectical Behavioral Therapy (DBT). The curious can follow this link for more about these alternative behavioral methods or this link for other treatments described in this course.