Like many girls, Ana has suffered a heartbreaking number of traumas in her short life that have decimated her self-confidence, filled her with anxiety, and snatched away her joy. Once a ray of sunshine in the home, dejected Ana is only a shadow of who she once was. At the bidding of her family, Ana finally agrees to go to a psychotherapist that uses cognitive behavioral therapy. But as she enters the therapist’s office, Ana thinks to herself, “I will never get better. What’s the use?”
“The first step for Ana to change her negative, self-fulfilling cycle is to become aware of her thought process.”
Cognitive Behavioral Therapy (CBT) is an evidence-based structured psychotherapy that focuses on changing unhelpful thinking and behavioral patterns resulting in healthier ways to cope with life stressors. CBT is shown to be effective in treating mental health disorders such as depression, anxiety, personality disorders, marital issues, and substance use disorders. [i] Many studies show CBT to be as effective as, or more effective than, other psychological therapies or even psychiatric medications. [ii] Since the 1960s, CBT has made significant advances based on research and clinical practice alike. Today, it is considered the gold standard psychotherapy.[ii] CBT is set apart from many other forms of psychological treatment because there is abundant scientific evidence that CBT methods produce actual change.[ii]
Although CBT therapists gather a significant history, they primarily focus on client’s current lives as opposed to their past. CBT homework often focuses on reframing negative automatic thoughts. It is ideal to work under the guidance of a CBT therapist, however, you can learn and begin practicing the basic principles of CBT.
How CBT Works
Cognitive Behavioral Therapy helps you develop awareness of your triggers, self-talk or automatic thoughts, emotions, and behaviors.
Remember how Ana first went into therapy thinking, "I will never get better. What's the use?" She may not even be aware that she said this negative automatic thought. Ana will feel hopeless if she truly believes that she won’t ever get better. And because she feels hopeless, more than likely she won’t be fully engaged in the therapeutic process and will only make half-hearted attempts to do the homework given in session. If she doesn’t change her thinking or behavior she won’t get better. She would then obviously maintain her belief that she won’t get better and will believe that her thought is valid, when in reality, her thoughts would be a self-fulfilling prophecy. The first step for Ana to be able to change this negative self-fulfilling cycle is to become aware of her thought process.
Several steps help us understand CBT better.
1. Hear Your Internal Dialogue
In order to develop awareness of your own negative thought process, you can use a simple thought record to begin to log your negative automatic thoughts.
But first let’s understand how our mind works. We first experience an activating event or situation, which then leads to an automatic thought. The situation itself does not determine your automatic thought, but how you perceive the situation is what determines your automatic thought. Following your automatic thought, you will experience an emotion, which then determines a behavioral and/or physiological response. For example, the situation for Ana was walking into the therapist’s office. Her automatic thought was, “I will never get better. What’s the use.” She felt hopeless as a result of her automatic thought and as a behavioral response she made little effort to improve her psychological well-being.
Recognizing how your thoughts impact your own well-being is important so that you can discontinue negative thought patterns like the one Ana found herself in. If you tend to stuff or avoid your emotions and thoughts, this may take some time to master. An easy way to start is to notice emotions that cause distress. Emotions get our attention more rapidly than our thoughts do. Your emotions can be your cue to hone in on any potential thoughts or images that may have contributed to your emotional distress. (When I first was taught how to do this in graduate school it took me two whole weeks before I could even begin to understand what I was thinking when I had any distressing emotions due to the habit of avoiding my negative emotions).
If you can’t determine what you are thinking, hypothesize as to what you think you may be thinking. This will help you to begin to strengthen the skill of self-reflection and eventually begin to understand yourself more fully, therefore helping you to apply the appropriate intervention.
2. Analyze Your Internal Dialogue
Once you have identified a negative automatic thought or a theme in your negative automatic thoughts, it is helpful to determine whether your thought is indeed true. You can do this by reviewing the list of cognitive distortions to determine if your negative automatic thought fits the description of a common distorted or irrational belief.
Cognitive distortions are common crooked or irrational beliefs. If you determine that you have a cognitive distortion, then you have agreed that your belief is irrational and is need of change to a more rational thought. In Ana’s case, the belief that she will never get better falls into the category of all-or-nothing thinking and fortune-telling. All-or-nothing thinking is when one sees things in two categories. Things are seen as black and white, with no shades of gray. [iv] We know this belief is all-or-nothing thinking because she uses the word “never” when she says, “I will never get better.” Fortune Telling is when one makes a “negative prediction about what will happen when other outcomes are more likely.” [iv] We know that she is using fortune-telling because she has been through other stressful events in the past and was able to overcome them through the use of counseling. She also may be doing some emotional reasoning because she has drawn the conclusion that she will never get better due to how she feels and not based on evidence.
“Test whether you have sufficient evidence for your negative automatic thought”
Another way to determine if your negative automatic thoughts are true is to test whether you have sufficient evidence for your negative automatic thought. This can be done through the use of socratic questions such as, “What makes me think the thought is true?” or “What makes me think the thought is not true or not completely true?” [iv]
For example, Ana has been through difficulties in the past and with the help of her CBT therapist and social support she has overcome those difficulties. So there is very little evidence to support her belief that she “will never get better.” Now, she may believe she has evidence because she feels really depressed. But are our feelings sufficient base to draw a conclusion upon? Sometimes the evidence you may think you have for why something may be true may not be evidence at all. Feelings often lie and aren’t a sure guide. However, it is important to find evidence for why the thought may or may not be true and then rate it from 0-100% as to which side holds more weight. Practice using the Beck Institute Testing Your Thinking Worksheet.
Once you have determined whether your thought is true or not, you can determine if your belief is helpful by the use of a cost and benefit analysis (see figure). The figure to the right is an example of the advantages and disadvantages if Ana were to continue to believe her negative automatic thought, “I will never get better. What’s the use?” vs. the alternative to her negative automatic thought, which would be to use problem solving skills and positive thinking.
By using this model you can determine if your thought, whether true or not, is helpful. If it is not helpful then it is best to consider an alternative way of thinking.
3. Reconstruct Your Thinking
To develop an alternative way of thinking about a negative automatic thought (NAT) you can use the evidence against the NAT to reframe the thought. For example, with Ana she had evidence of having gone through something difficult in the past and was able to overcome it with the support of her CBT therapist and social support. So she could use this evidence to tell herself, “Although it feels impossible, I don’t have sufficient evidence to believe it is impossible because I have gotten better before when I was in a similar position. Feeling is not evidence of what will take place in the future. Plus, I can’t predict the future.” It is important that when you are reframing your NAT that you develop something that you can believe, otherwise it won’t be helpful in reducing your emotional distress. However, there are circumstances that when even actual evidence is not believable for someone who has severe depression or anxiety. In this case, it will take more effort to internalize the truth. But don’t give up because it is important to address the root of the anxiety and depression and uproot the lies that we tell ourselves.
If you are still having difficulty finding a way to dispute or reframe your NAT, it is sometimes helpful to imagine what you would tell someone that you love if they were in a similar situation. You often will find that it would be difficult to tell someone you love the negative self-talk that you tell yourself. Do you think Ana would tell her younger sister that she would never get better and that there was no use in trying? More than likely not.
Once you have determined that new positive, helpful way of thinking you can put it on an index card to create flash cards. You can even develop multiple flash cards and use a ring to hold them together. Depending on how often you entertain your NATs you would want to just as often pull out your flashcards to review the new way of how you want to think about things. You may experience immediate relief from emotional distress or it may take time. If you are concerned about others seeing you pull out flash-cards you can use your notes on your phone to reframe your negative self-talk.
Time and practice are central to understanding cognitive behavioral therapy. The reward is well worth every effort. You have incredible power to change your negative, automatic thoughts. Use the steps outlined in this article and download the resources provided. You can experience a change in both behavioral and emotional responses to thoughts and situations in your life.
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[i] Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive therapy and research, 36(5), 427–440. doi:10.1007/s10608-012-9476-1
[ii] American Psychological Association (n.d.). What Is Cognitive Behavioral Therapy? Retrieved from https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral
[iii] David, D., Cristea, I., & Hofmann, S. G. (2018). Why Cognitive Behavioral Therapy Is the Current Gold Standard of Psychotherapy. Frontiers in psychiatry, 9, 4. doi:10.3389/fpsyt.2018.00004
[iv] (n.d.). Home. Retrieved from https://beckinstitute.org/
About the author
Christina Cecotto is a Licensed Clinical Social Worker with an international emphasis in crisis and trauma. Her primary modality is Cognitive Behavioral Therapy and she supports a holistic lifestyle approach with her clients. Christina is a regular therapist at the residential Nedley Depression & Anxiety Recovery Program. Christina is an avid lover of the great outdoors; she enjoys hiking, rock climbing, biking, kayaking, and traveling with her husband, Nicolas, and her dog. Learn more about Christina and coaching opportunities at www.christinacecotto.com.