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Cognitive Behavioral Therapy

Why Do Cognitive Behavioral Therapy?

  Cognitive Behavioral Therapy (CBT) is based on three simple principles:

  1. The way you feel about a situation has more to do with how you interpret it – that is, the  “story” you tell yourself about it – than with what actually happened.

  2. When your stories or interpretations are inaccurate, distorted, or incomplete, you tend to have negative emotions (like fear, anger, depression, etc.).  

    Conversely, the more accurate and constructive your story is, the more likely you are to have positive emotions (like happiness, compassion, appreciation, and gratitude).

  3. By changing your story or interpretation, you can change the way you feel about what happened. 

How Do CBT Techniques Work?

          CBT techniques help you to identify the distortions in your stories that are creating negative emotions.  Once you’ve identified and challenged the distorted elements of your story, you can then create a more balanced and accurate story that will result in more constructive action and more positive emotions.

          In recent years, cognitive-behavioral therapy has been combined with mindfulness meditation – meaning that “remembering to breathe” has become an essential part of the process. “Remembering to breathe” is our shorthand for anchoring your attention at the hub of your wheel of awareness, thereby activating your MPFC – the part of your brain that brings balance and harmony to your body, mind, and emotions.  

          The more you’re centered at the hub and the more active your MPFC, the easier it will be for you to see the distortions in your stories, as well as different, more constructive interpretations. Research has shown that the combination of mindfulness and CBT is more powerful than CBT alone.

                          Cognitive-Behavioral Therapy in Action

          The following story by Dan Greyling, written for Reader’s Digest, illustrates the power of interpretation to shape one’s emotions:

“A friend of mine, returning to South Africa from a long stay in Europe, found herself with some time to spare at London’s Heathrow Airport. Buying a cup of coffee and a small package of cookies, she staggered, laden with luggage, to an unoccupied table. She was reading the morning paper when she became aware of someone rustling at her table. From behind her paper, she was flabbergasted to see a neatly dressed young man helping himself to her cookies. She didn’t want to make a scene, so she leaned across and took a cookie herself. A minute or so passed. More rustling. He was helping himself to another cookie. By the time they were down to the last cookie in the package, she was very angry but still could not bring herself to say anything. The young man then broke the remaining cookie in two, pushed half across to her, ate the other half and left.”

          It wasn’t until sometime later when she opened her handbag to take out her boarding pass, that she saw her own package of cookies there inside.  Not only had the young man not been eating her cookies, she had been eating his - and he was graciously sharing them with her! So, clearly her anger was about her “story” of what happened – not the actuality.  

          But what if the young man really had been eating her cookies?  Would anger have been the only possible reaction to the situation?  

          Not necessarily.  

          It’s possible that the woman could have been amused by the brazenness of the young man’s behavior, at the utter audacity of offering her one of her own cookies.  

          Or she may have thought that maybe he'd lost his wallet, was hungry, and was too embarrassed to ask for a cookie. And she may have been very happy to quietly help him out.  

          Or she may have interpreted it as a flirtatious gesture and been flattered. 


          When you start looking into the CBT techniques on this site, you’ll discover that there are many, quite varied ways of interpreting any situation – which means there are also many different ways to feel about it. 

Is It Really Possible Not to Get Angry?
The Story of Tony


         Some years ago, Don taught stress management workshops at a VA Hospital, for veterans who suffered from diabetes (reducing stress has been shown to lower blood sugar levels).  He would start the class by explaining how stress works.  (You can read more about how stress works on the Stress Management page.)  

         His introduction to the class usually went something like this:

         "Millions of years ago, our nervous system evolved in such a way that whenever we were in physical danger from a predator or some other physical threat, it would provide us with a rapid burst of energy. This gave us the ability to either fight or flee from the source of the danger.   

         If we fast-forward to modern times, the threats we’re now more likely to encounter are of a psychological nature – threats to our sense of who we are, insults to our pride, thwarted desires, etc.  But our nervous system hasn’t kept pace with the changes in our civilization, which means it continues to react in the same way it did millions of years ago when our physical survival was at stake.  Our bodies rev up, releasing thousands of stress chemicals into our bloodstream.

         Back in the jungle that all worked very well.  When we fought or fled from a predator, we “used up” the extra energy, and soon afterward, our nervous system and biochemistry would return to a state of balance.  However, in the modern world, when we react to something or someone, we don’t usually fight or flee, and so we don’t use up the energy. We also have a tendency to keep going over the danger in our heads – something our ancestors didn’t do.  As a result, our brain continues to release more stress chemicals into our body, creating all kinds of imbalances, and ultimately leading to heart disease and other stress-related disorders." 

         After giving this introduction to stress, Don would explain the basic principle of CBT – that it’s not the situation that causes our stress, but rather the “story” we tell ourselves about the situation.  Then, to be a bit provocative, he’d say, ‘This means that no situation or person can force you to feel a certain way.  For example, it means that nothing can make you angry." 

         Well, that last statement almost always made at least one person very angry.  So he’d ask the person to come up with an example of a time when he (or she) had gotten angry.  Usually, after playing around with a few different interpretations of his situation, he’d be quite surprised to see how much more choice he had about how to interpret it, and therefore about he could respond to it as well.

         But one day, Don was taken by surprise.  He had just given an example - that in modern times, when we’re angry about something our boss does, we’re not likely to beat him up because it’s not culturally acceptable, and it’s not an effective way of resolving the stressful situation.  

         At this point, Tony, one of the veterans in the class, piped up saying, “Hey, I punched my boss, and it worked out great!”  He then went on to describe two incidents in which he’d gotten angry and physically assaulted a superior at work, but in both cases had been promoted to a higher position.

         Don was at a loss as to how to respond, and figured it was a good time for a bathroom break.  The break provided him with a perfect “remember to breathe” moment:

         "I literally took a long, slow breath and stopped trying to figure out what to say. My mind got (relatively) quiet, and suddenly an image took shape.  

         When Tony got back to the room, I said, “Imagine this – pretend you’re just walking out of an elevator and some guy with an angry scowl on his face bumps into you.  How would you react?”

         Tony answered,"I’d be angry and I’d shove him back."

        "What if I told you he had a congenital disorder that affected his face in such a way that he always looked angry, and that he was blind?"

          Tony paused a minute to take this in.  "So you mean I couldn’t tell he was blind by looking at him?"

         "That’s right."

         "And he didn’t bump into me on purpose?"

         "Right." 

         There was a long pause…. then Tony responded, "so you mean that I got angry because I misinterpreted what he was doing?"

         I just nodded and smiled.  Tony looked very thoughtful, didn’t say anything more, and sat back in his chair.

                                                     *  *  *  *  *  *
  *  *  *  *

         "About eight months after this class, I was walking through the hospital, and heard someone call, 'Doc, hey Doc!'  I looked around, and saw a man sitting nearby, looking at me.  'Don’t you recognize me?' he said. I was stunned. It was Tony – but he looked completely different.  He’d lost over 70 pounds (down from more than 240) and had a gentle smile on his face.  He told me that he’d been so struck by our conversation in the stress management class, that he spent several months looking back over his life.  

         He went on to share with me that he had grown up in a dangerous, crime-ridden neighborhood, and was taught from a young age to be wary and suspicious of other people.  He had learned to cope by being ready to fight at the slightest provocation, no matter what the consequences. But after the class, for the first time in his life he realized that he didn’t have to be on guard all the time, and that much of his anger was unwarranted.  

         We sat and talked for a while, and I told him how grateful I was to know that something I’d said had made a difference for him.  He thanked me and we said goodbye."


-

How to Undo Our Distorted Interpretations and
the Stories We Tell Ourselves

 The Mindful Cognitive Approach

           So what can we do about these distorted stories and interpretations that make us feel bad, drive us to do things that usually aren’t helpful, and which we may later regret?

          Sometimes, simply sitting at the “hub” of the “wheel of awareness,” and from there calmly observing our distorted thoughts and stories, is enough to take away their power to make us react.  

          But the hub may not always be easy to access.  Sometimes our stories are so complex, and so rooted in years of past experience, that we need to do some work to unravel them before we can see our way clear to the hub.

          And that’s where the various CBT techniques come in.  Although there are literally hundreds of CBT techniques, they’re all variations on one essential CBT process.

Phase 1: 

          The first part of the process is designed to help you hold your story lightly.  That means understanding that the story is something you’ve constructed, rather than taking it to be the absolute truth.  For example, rather than holding on to an inflexible story like, “He’s a bad person who says things just to hurt me” you might recognize that he has both positive and negative traits, and that you don’t really know what his motivation is when he says things you find hurtful.

          So how do you hold something you’re upset about lightly?  By remembering to breathe.  

          And how do you remember to breathe?  You might simply need to take taking a few deep breaths to get a taste of the calm and ease of the core.  Or you may be able to just calmly be mindful of the story and your reaction to it.  Or you can use a technique – breathing, relaxation, or imagery – to help you connect to the core, the hub of your wheel of awareness.

          Simply strengthening your connection to the hub may be all you need in order to shift your attention away from the negative thoughts and emotions related to your story, restore a sense of emotional balance, and feel free to go on with your day.

          But if you want to do more than feel better about this particular situation, if you want to prevent future reactions and negative emotions from being triggered, you can continue on with the next part of the process.
 
Phase 2:  

          In this part of the process, you’ll begin to identify the beliefs and assumptions underlying your story.  After you identify what they are, you’ll test their accuracy by “examining the evidence” for those beliefs and assumptions.  Keep in mind that although this may sound like a very logical, rational process, it’s only effective if it takes into account your emotions as well as what your body is experiencing.

Phase 3:

          Once you see that your underlying beliefs and assumptions may have been distorted – in other words, that your story about what’s going on is not the same as what’s really going on - you can begin to rewrite your story in a way that is more accurate and will be more supportive of constructive feelings and actions.

          As an example, let’s say you had a rough day. Lots of unexpected things took your attention, you didn’t finish what you wanted to get done, and you feel so tense and discouraged that you start to have thoughts about being a total failure.  You can feel yourself falling into a mood of rather intense depression, along with feelings of anxiety and overall tension.  

          Let’s say you then identified a belief that contributed to those feelings – the belief that in order to be a responsible person and be worthy of love and respect, you have to constantly push yourself to be highly productive and successful, accomplishing multiple things every single day. This belief could certainly lead to considerable feelings of stress, anxiety, and depression.

      If you wanted to look at this belief using mindful CBT, you would start by remembering to breathe and simply recognizing that, in fact, you have a story about what it is you need to do in order to be a lovable, worthwhile person.  And you would need to acknowledge that that story may not be 100% accurate. It's possible that might be enough to alleviate the mood of anxiety and depression. But if not, you would go on to examine the story in more detail.


     You would then use any number of techniques to investigate what about the story may be valid, as well as what might be an exaggeration, perhaps too black and white, or maybe even at odds with the reality. 

    CBT and Depression

      Aaron Beck, who originated the technique of cognitive behavioral therapy, observed that people who are depressed often hold the belief that other people don’t care about them, that they have little to offer. He discovered that in as little as 2 or 3 months, just by changing these beliefs, depression could be reduced or even cured.

      In fact, one of the most consistent findings regarding the effectiveness of cognitive behavioral therapy is that it can be as effective as medication in treating even severe cases of depression.

          And finally, you would retell the story to correct for the distortions, decrease your anxiety level, and provide a more balanced and productive basis for living your life.

          For example, you might see that you have a sincere intention to make productive use of your life and to contribute in some way to making a better world.  You might also see that your sincere intention has been mixed up with, and distorted by, the notion that if you’re anything less than a total workaholic, it means you’re not trying hard enough.  You might see that that notion  has given a compulsive quality to all you do, taking the joy out of your work and your life.  You might also see that the story has caused you great anxiety and that your priorities have been out of balance.  So you might, while centering yourself as much as possible in the hub of calm acceptance and non-judgment, create a new story that both honors your sincere intentions and places value on things you’ve been ignoring (like relaxation and relationships) – a story that doesn’t tie your entire self-worth to how much work you accomplish.

The “Behavioral” Approach

          Sometimes cognitive techniques alone are not enough to undo a story – particularly if it’s one you’ve held for many years, or one you strongly identify with.   In such cases, behavioral techniques can be particularly powerful – trying new behaviors and ways of interacting with people that challenge your beliefs and long-standing patterns of thinking and feeling.

           In Ellen Langer’s book, Counterclockwise, she describes an experiment in which a group of men in their 70s and 80s spent a week acting as if they were 20 years younger. During that week they stayed in a monastery which had been specially set-up to resemble the world of 20 years earlier. While there, the men watched movies, listened to music, read magazines, and discussed news events all from the earlier era.  

          The result of this behavioral experiment?   The men experienced improvements in hearing, memory, height, weight, gait and posture. Their arthritis diminished, their joints were more flexible, and they had more manual dexterity. They also showed improvements on measures of intelligence. Objective observers who knew nothing about the experiment looked at two sets of photos of the men – one that had been taken before, and one after the experiment.  Though the observers didn’t know the time sequence of the photos, they all said that the men looked younger in the second set of photos!  And all of this was the result of simply acting as if they were younger.


          Sometimes a behavioral technique can accomplish rather quickly what would take longer using a purely cognitive approach. The teacher in the following story used a behavioral technique for challenging her students’ stories about themselves.  She may not have realized exactly what she was doing but, as you’ll see, the effects of her “behavioral experiment” were profound and long-lasting.

          On one particularly fidgety and distracted afternoon [a high school teacher] told her class to stop all their academic work. She let her students rest while she wrote on the blackboard a list of the names of everyone in the class. Then she asked them to copy the list. She instructed them to use the rest of the period to write beside each name one thing they liked or admired about that student. At the end of class she collected the papers.

          Weeks later, on another difficult day just before winter break, the teacher again stopped the class. She handed each student a sheet with his or her name on top. On it she had pasted all twenty-six good things the other students had written about that person. They smiled and gasped in pleasure that their classmates had noticed so many beautiful qualities about them.



          Three years later this teacher received a call from the mother of one of her former students. Robert had been a cut-up, but also one of her favorites. His mother sadly passed on the terrible news that Robert had been killed in the Gulf War. The teacher attended the funeral, where many of Robert’s former friends and high school classmates spoke. Just as the service was ending, Robert’s mother approached her. She took out a worn piece of paper, obviously folded and refolded many times, and said, “This was one of the few things in Robert’s pocket when the military retrieved his body.” It was the paper on which the teacher had so carefully pasted the twenty-six things his classmates had admired about him.



          Seeing this, Robert’s teacher’s eyes filled with tears. As she dried her wet cheeks, another former student standing nearby opened her purse, pulled out her own carefully folded page, and confessed that she always kept it with her. A third former student said that his page was framed and hanging in his kitchen; another told how the page had become part of her wedding vows. The perception of goodness invited by this teacher had transformed the hearts of her students in ways she might only have dreamed about.

Cognitive Behavioral Therapy and Brain Integration

          As we explain on the Brain Pages of the site, the key to well-being is a well-functioning brain.  And the key to a well-functioning brain is integration – which means that the various parts of the brain and body are working together in harmony.  

          There are various ways in which the brain is integrated, which we describe in more detail on the Brain Integration pages.  But the most essential form of integration is harmony between the core or hub of our awareness and the contents of our awareness.  It’s a lack of this basic integration that’s at the root of all our reactions.  

          Once we realize the basic principle of CBT – that it’s not the event, but our story about the event that causes our reactions – all we need to do (in theory!) is “remember to breathe,” to re-center ourselves at the core of our awareness.

          From there, we can observe calmly and without judgment, the event and our reaction to it.  That simple act of calm, nonjudgmental observation changes the firing of neurons in our brain, taking some of the “power” or “charge” out of our reaction, and making it possible for us to see and respond more clearly and effectively.

          That’s the theory.  But in practice it’s often not quite that simple because there are so many parts of us that are in conflict – that is, so many parts that are unintegrated. Our mind and heart are out of sync with each other, the needs of our body often conflict with our desires and theories about what our bodies need, and we have different “selves” or personalities that are not in harmony.  And all that conflict makes it hard to find the hub.

          Cognitive behavioral therapists have found that the distorted beliefs and stories about ourselves and the world that are responsible for our negative emotions, are distorted in particular ways. Each of these distortions involves a particular lack (or lacks) of integration.   

          For example, one very common distortion is known as “mind-reading.”  We’re mind-reading when we assume we know what someone else is thinking about us.  If our mind-reading generally takes the form, “that person doesn’t like or care about me,” our overall mood is likely to be depressed. If, on the other hand, our mind-reading takes the form, “that person can’t be trusted, they’re out to take advantage of me,” we’re likely to feel anxious, impatient, and easily angered.

          Tony, in the story we told above, confided to Don that he’d spent his life “mind-reading” other people’s intentions in a way that led him to feel angry a great deal of the time.  The woman who sat across from the young man eating “her” cookies, had also assumed something about the man’s motivation that she had no direct way of knowing.  
 
          These examples of mind-reading involve a lack of what Dan Siegel calls interpersonal integration – the ability to sense what another person is experiencing.  Neither Tony nor the woman were able to step back from their own reactions enough to see clearly what was going on with the other person.  

          These examples also involve a lack of left-right integration.  Our left hemisphere tends to focus in on a few details – a person’s expression, a particular thing they said – and then weave a whole story about the person based on those few details, without taking the larger picture into account (which is the job of the right hemisphere).  

          In both examples there was also a lack of vertical integration – that is integration between the upstairs and downstairs brain.  In both cases, the emotional reactions of the downstairs brain got the better of the upstairs or thinking brain’s ability to see clearly. Tony reacted impulsively to his distorted interpretation of people’s intentions, and the woman reacted with irritation based on her mistaken assumption about the young man’s intentions.

          As we said above, sometimes just stepping back into the calm hub of awareness can create sufficient detachment from our distorted story to calm our reaction.  But much of the time something more is needed.  By examining the specific ways that our stories are distorted, and seeing what parts of our brain are not integrated, it’s possible to dramatically change the way our brain functions, helping to make our stories more balanced, and give us a feeling of greater balance and harmony overall. 

The CBT Techniques

          We describe and guide you through a number of CBT techniques on the following pages: