Judith S. Beck, PhD, President
“I lost my home and all of my possessions in a flood.”
“The business I worked for went bankrupt and closed down.”
“My child has a terminal illness.”
A common myth is that the entire premise of Cognitive Behavior Therapy (CBT) is that clients’ distress is related to their distorted cognitions. So how does CBT help individuals whose cognitions are accurate, reflecting real-life problems?
A fundamental misunderstanding is that CBT therapists do not consider the context of problems, only the client’s internal reaction to problems—and therefore have little to offer individuals who are facing objectively adverse circumstances. It is unclear how this myth arose, but it can prevent individuals from getting the help they need.
Take the situation where someone has lost their home, all their possessions, and even their pets in a natural disaster such as a flood, tornado, earthquake or wildfire. Of course they will be quite distressed. Most will not seek therapy but may benefit from support and guidance from family, friends, or community members. Those who seek therapy fall into two groups: Clients who benefit from a supportive, problem-solving approach and those whose symptoms are severe and persistent enough to warrant a mental health diagnosis. It is this latter group for which a standard trial of CBT is appropriate.
When Ashley’s house was destroyed in a hurricane, along with the homes of most of her community, she was distraught: “We’ve lost everything. I can’t count on my neighbors or my friends [who live nearby]. What can I do?” Ashley’s thoughts were reality-based and problem-solving oriented. She didn’t need psychotherapy. But she did need some help. She and her two young children were able to obtain temporary shelter at a community center. There, she spoke to a kind volunteer who helped her sort through her options:
- Investigate whether any of her friends, whose homes were intact, would be willing to take in her family, at least on a temporary basis.
- Contact her aunt who lived two states away but was sure to invite her to move in with her.
- Find out whether any family members were able to help her out financially, or whether there were FEMA or other funds available to stay in a nearby motel.
Ashley decided to call her aunt. Although she was still quite upset, she felt more in control once she had formulated this plan.
Mark* found himself in a similar situation. His home burned down, as did all the houses in his neighborhood. He needed more than a friendly person who could help him consider his options. Mark was wracked by indecision and had become quite depressed. “We’ve lost everything. I don’t know what to do. Everyone is counting on me. I’m letting everyone in my family down. I’m failing them. I can’t get it together. Everything is falling apart. This is completely overwhelming. We won’t be able to survive this disaster.” While Mark, too, needed help in solving some immediate problems, he needed much more.
When conceptualizing a client like Mark who is experiencing a depressive disorder as a result of a real-life challenge, a CBT therapist needs to help the client evaluate their upsetting thoughts:
- What is the evidence that the thought is true?
- If true, is it helpful?
- Now that the worst has happened, how can I cope?
- What is the best outcome I can reasonably expect?
- What is the most realistic outcome?
- What is the effect of continually focusing on the worst outcome?
- What would I tell [my best friend] if they were in this situation and had these thoughts?
- What can I constructively do now?
This process of Socratic questioning was helpful to Mark in changing his negative self-perception, but he continued to engage in obsessive thinking, making dire predictions about the future—even after he recognized how maladaptive this thought process was. I hypothesized that he had underlying beliefs that were interfering with his motivation or ability to disengage from these thoughts. I asked him what he saw as the advantages of continuing to think in this way. He responded, “If I worry about what could happen, I can try to make a plan to avoid it.” He also reported, “In any case, I don’t have any control over my thinking. I can’t stop thinking that way.”
When we examined the evidence, it became clearer to Mark that his worry was unproductive, that it did not lead to the generation of options or solutions but merely maintained his constant anxiety. Then I proposed an experiment to see whether Mark could take some control over his thinking. I asked him to worry intensely for a couple of minutes. Then I introduced a mindfulness technique: “Mark, I’d like you to focus on your breathing. You’ll find that when you do that, you may stop obsessing for a few seconds. Then you’ll start again. So I’d like you just to notice that, don’t judge yourself negatively, but bring your attention back to your breathing. Can we try to do that for about five minutes?”
When he agreed, I asked him to record my voice on his cell phone app. In a calm, gentle voice, I coached him to focus on his breathing and to non-judgmentally refocus when his attention wandered. Afterwards, I asked him about this experience. He said he felt calmer but thought he should have done a better job because his mind often wandered. I reminded him of something I had said during the exercise: “If your mind is wandering, that’s okay. Minds are supposed to wander. Just bring your attention back to your breathing.” I asked him whether he thought he could be better able to focus if he practiced this exercise, listening to the recording, at least once or twice a day. He agreed to make that part of his Action Plan. At the following session, I taught him how to add informal mindfulness practices to his more formal practice.
There were many other aspects of treatment that were particularly helpful to Mark, including identifying his values and aspirations, learning how to defuse and detach from his negative thoughts, planning how he could take at least small steps in line with his values each week, weighing advantages and disadvantages of various options he had, accepting his changed circumstances, solving problems and making decisions, engaging in pleasurable activities with his wife and children, and reconnecting with extended family. Mark was able to focus on what was most important to him in life, respond to negative thinking that was interfering with fulfilling his aspirations and living in line with his values, and rebuild a good life for himself and his family.
Most individuals with a mental health problem don’t face the kind of disasters that befell Ashley and Mark. But CBT therapists help every client with real-life problems—because almost everyone has problems! These problems can often be solved. When they can’t, the therapist conceptualizes how best to help the client, which often involves accepting that the problem exists, changing their focus to what is under their control, and living in accordance with what is most important to them in life, even if it’s in a different way from how the client originally hoped or planned.
CBT is not about ignoring reality or insisting that clients “think positive” no matter their circumstance. Instead, it helps clients accept reality, reduce distress, cope with problems, and build resilience—even when facing profoundly difficult situations.
*The client’s name and identifying details have been changed to protect confidentiality.