In the course of my twenty-five years of clinical practice, I have found a number of common errors that can prevent cognitive-behavioral therapy (CBT) from being as effective as it could be. The following describes these errors and how to correct them.
A few years back when I was lecturing a group of psychiatric residents (future psychiatrists) about using CBT with sexually traumatized clients, one of the doctors stated “I tried that cognitive therapy with my patients and it doesn't work at all!” As I explored with her the specifics of what she had tried with her patients, I ascertained that, basically, she had told them how they should think and then expected them to change their thinking.
When I asked her what method she used to help them practice and repeat the new ways of thinking in daily life, she was speechless. I then explained that the key to successful cognitive therapy was repetition of the statements that challenge the irrational thinking and that the therapist must use a method to help clients do that.
People don't change their thinking just because they are told to think differently. If that was the case, most people wouldn't need CBT because someone else has probably already told them how they should think. The difference with CBT is that a variety of methods have been developed to provide the steps to change thinking.
The importance of repetition as a key component of CBT can't be emphasized enough. This is true of any new skill. When I was training for my black belt in Kenpo karate my instructor told me “When you have done this self-defense move 6,000 times, it will be automatic.” And he was right! At first, I was awkward and slow in executing the movements. I had to think about every aspect of each move. I thought initially that it would never be automatic. However, I continued to practice. One day (after years of training) when I was teaching one of the brown belts, I realized that I was able to automatically respond to a wrist grab and put him on the ground without even thinking about it.
Changing your thinking is learning a new skill in the same way you learn a physical skill. You don't expect to be a proficient golfer without swinging the club a few thousand times. In fact, in the book “Outliers” by Malcolm Gladwell, he sets the magic number for success at 10,000 hours. According to Gladwell, when we examine the lives of the most successful people in any sport or profession, we typically find that they have spent at least 10,000 hours honing their craft.
Certainly, that doesn't mean that it will take 10,000 hours to change your thinking and to have a positive impact on your life. In fact, with frequent repetition of the rational challenging thoughts you should notice changes in four to eight weeks. However, you will need more repetition than that for the new way of thinking to become automatic.
Think of it this way. How many hours have you spent in your lifetime repeating the detrimental irrational self-talk? You likely have become very automatic in that way of thinking so now you need to re-train your brain to think in a different way. To do that you need to identify specific thoughts that are beneficial and to deliberately think those thoughts repeatedly.
Sometimes it is difficult to achieve the necessary repetition especially when you are first learning. That is why reading articles about CBT or motivational thinking can be helpful. The more you read, the more repetition you obtain. Also, that is why I have created some audios that focus on changing thinking. The audios provide repetition without a great deal of effort.
Many times when I first explain cognitive therapy to clients and we examine their irrational thinking and explain why it is irrational, they exclaim “That makes so much sense! I've never thought about it that way before!”
However, for some people, once they understand the process of using irrational thought challenges, they believe that that they should just be able to think that way without having to examine their thinking and deliberately change it. They make the mistake of using social comparison assumptions. In particular, they might state “I should be able to just think this way. Everyone else doesn't have to do this (referring to the CBT methods).”
What they don't realize is their assumptions about others not using CBT techniques is inaccurate. Just about anyone who is successful in life is using these techniques! However, they may not have been taught the techniques of CBT specifically and they may not know the terms such as “mind-reading” or “generalizing” but they are still using the methods.
I tend to think that CBT is just a compendium of methods that have helped people achieve success for thousands of years. For instance, if you read the “Tao te Ching” examining it for cognitive concepts, you will find that it contains all the same challenges to irrational thinking and methods of successful living that you will find in any book by Aaron Beck, Albert Ellis, or David Burns.
If you listen closely to people, you will begin to recognize how they apply these methods in their lives. For instance, I frequently hear people (outside of the office) say when describing a difficult event, “...but then I told myself...” In other words, they were using self-talk to cope with a situation. I've also heard people say things such as “Then I took a deep breath and...” describing how they calmed themselves before tackling a problem.
So don't assume that because you are having to learn these methods and deliberately apply them that you are doing something others don't have to do. The only difference is that you may not have learned the methods naturally while growing up and you are learning them now. You may not have had the role models or opportunities to learn these methods when you were young.
People aren't naturally successful. Anyone who is successful, whether in life, sports, career, or relationships, has learned these methods at some point in their lives and are applying them routinely.
Many people don't realize that CBT is training the brain to react differently to situations. As a result, they often mistakenly believe that recognizing the error in thinking and correcting it a few times will impact a change in their life. After they have some initial benefit they may believe that it isn't necessary to continue practicing the methods.
However, cognitive-behavioral changes need to be thought of as lifestyle changes just as exercise or an effective diet is a lifestyle change. You wouldn't expect to exercise for a few months, tone your muscles, stop exercising and expect your muscles to remain toned. Nor, is it reasonable to expect to lose weight by restricting your calories but not expect to gain weight when you return to eating everything you want.
A lifestyle change refers to any activity or behavior in which we engage regularly to maintain our health. In the case of the CBT methods, we make a change to improve our emotional fitness. But we can't expect that fitness or change to remain intact if we don't devote attention to practice.
People have come to realize that the body needs maintenance to retain fitness and optimum health. Too often, however, people think that the brain does not require maintenance. Therefore, many people obtain initial benefits from CBT but will revert to prior thinking patterns and behaviors due to the lack of attention to the CBT methods.
A good example of what may occur is the use of relaxation methods during a time of stress. The regular use of relaxation reduces the degree of stress experienced. However, many people are likely to think “I feel good. I don't need to do this relaxation anymore.” However, stopping the relaxation practice may result in a return of the symptoms associated with stress.
Unfortunately, when this occurs some people may conclude “That relaxation stuff really doesn't work!” However, that is like saying exercise doesn't work because when you stop exercise you lose muscle strength.
A closely associated error is that many people believe they should obtain benefits from relaxation even though they use it infrequently. I can't tell you how often clients report being stressed or anxious, yet when I ask them how often they engaged in relaxation, they respond “once” or “not at all.” The same clients, however, may report a very positive response from the relaxation when they use it.
Again, the regular practice of relaxation trains the brain and the body to respond differently. This practice can create a very powerful response. You may be familiar with strong automatic negative responses. For instance, if you have been very stressed at work, you may notice your body reacting with symptoms when you drive by you place of employment on your day off. Our bodies can become conditioned to stress responses and associate the stress response with a place, person, or thing.
However, our bodies can also become conditioned to the relaxation response. I had an experience once that illustrated to me just how powerful the relaxation response can be. Years ago I listened to a particular tape (before CDs and MP3s) whenever I had a stress headache. One day, years later, while I was driving and listening to the radio, my entire body suddenly relaxed. I felt an incredible, soothing peacefulness. Wondering why I suddenly felt so relaxed, I realized that one of the songs that I used to listen to was playing on the radio. My body had become conditioned to relax to that music.
To be able to experience the powerful benefits of relaxation, however, it is necessary to practice regularly.
Very closely related to the importance of using the methods regularly, is the expectation many people have that using the methods one time should be effective. In the course of my practice, I have frequently heard a client say, “I tried breathing when I was anxious and it didn't work.” When I asked them how much they had practiced prior to using it for the anxiety, they have told me not at all or very little.
If you were playing baseball, would you expect to hit the ball during a game if you had never tried hitting a ball before? Of course not! However, people often believe that the techniques of CBT should be effective when they have never practiced them. I think this may be due to the techniques being very similar to other normal daily behaviors so people think that they should just be able to do it without an previous training or practice.
For example, they might think that since breathing is something they have done every day of their lives, they should be able to just slow it down at will. However, the fallacy here is that although they have been breathing their entire lives, they have not been regulating their breathing at will. These are two different things.
To put this in perspective, if I asked you to lower your body temperature (without any artificial means such as ice) you might tell me I'm crazy, that it can't be done. But your brain has regulated your body temperature all your life just as it has regulated your breathing. So why do you believe that you can't lower your body temperature? Probably because you are not as aware of it as you are of your breathing. However, it is possible to change our physiological responses such as body temperature or blood pressure but it requires advanced practice. (And is not the topic of this article—I'm just using it to illustrate a point.)
The point is that practice is necessary to achieve the ability to change our physiological responses. We can't expect to be proficient at calming ourselves if we never practice the techniques. In CBT, homework is everything!
Another common error that people make about CBT is believing that it is all about positive thinking. I have frequently heard the remark, “I've tried that positive thinking—it doesn't work.” However, CBT is not about positive thinking at all. In fact, positive thinking can be just as irrational and problematic as negative thinking.
For example, if someone believes “Everything will be okay. I don't need to worry” when a catastrophe is occurring, they may not take the necessary steps to control the situation which allows it to become worse. There are times when we need to be concerned so that we can take appropriate action.
However, cognitive therapy approaches this in a realistic manner. If we are worrying about something that is not likely to occur, then we are making ourselves feel bad about something for little reason. Therefore, CBT is practical and realistic. It is about assessing our thinking so that we can take the most reasonable approach.
Sometimes people take CBT too far and believe “If I'm completely rational, I won't feel anything.” In fact, I heard Albert Ellis, one of the founding fathers of cognitive therapy, state this idea at a seminar. He said that if we are always rational, we would never be angry.
I hope I misunderstood his statement because I disagree with this concept. We are emotional beings. Emotions are an important part of our information processing system. Emotions allow us to be aware of problems that need to be addressed. So I neither believe that normal human beings can be completely free of emotions nor do I believe that it is healthy for us to not have emotions. Without emotions we can miss very important information in our environment.
For example, if you are threatened on a dark street late at night, what do you think reacts first? Do you think your emotions react first warning you of danger? Or do you intellectually assess the situation first? The initial emotional reaction prepares us to flee or to fight. The intellectual response is to determine what might be the better decision.
Certainly, our emotions can cause us to over-react. For instance, on that dark street you might feel threatened when you really aren't. And that is where CBT can help. It helps us to learn to keep our emotions in perspective and to recognize when we may be over-reacting. However, it should not be used to prevent emotions completely.
Many CBT therapists are finding standard CBT too limiting in this regard and there has been much movement to mindfulness-based CBT, often referred to as MBCT. MBCT focuses more on learning to tolerate the various emotional states through mindfulness approaches rather than trying to eliminate them. The intellectualized approach in standard CBT can be problematic for people who already have a more analytical style with avoidance of emotions.
As people learn about CBT, sometimes they come to believe that if being rational is good and benefits their life, they might place a demand on themselves: “I SHOULD be completely rational all of the time.”
Now, if you know anything about cognitive therapy, you know that this statement is irrational in itself for several reasons. One, is that it is a perfectionistic demand. Such demands are impossible to achieve which then causes additional distress and dysfunction. Cognitive therapy is about decreasing stress by being realistic in our expectations of ourselves.
Another reason this statement is irrational is because it is black-and-white reasoning which is the idea that if something is bad, the opposite should be good. But this isn't the case either. CBT is about finding balance whereas black-and-white thinking is about extremes. Even CBT when done to the extreme can be unhealthy.
I have often had this issue with my anxious clients. When we work on exposures to anxiety-provoking situations so that they can desensitize to the situation, they may come to believe that it is always good to challenge anxiety. In other words, if you are afraid of something, you need to face it. But that is not true because sometimes challenging a fear unnecessarily can cause more harm than good.
In particular, this attitude can cause unnecessary stress which may interfere with someone challenging the fears that are important to face. A person needs to evaluate a fear, determine in what way and how much it affects satisfaction in life, and then decide whether it needs to be dealt with. If I have a fear of snakes that doesn't really affect my life much, why should I face it? However, if it prevents me from doing something that is very important to me such as riding my bike on a wooded path, then I might choose to face it.
Another area where people need to be cautious with CBT is using it as a justification to not change or try. Although CBT teaches a person to appreciate all aspects of themselves, it is meant to be used for building a foundation that provides a stable base from which a person can make changes.
Practitioners of CBT believe that if you feel good about yourself, you will have greater confidence to try new things and to make improvements. You are more able to acknowledge your flaws or areas in need of improvement without that acknowledgment causing you to feel bad. So we teach acceptance of yourself.
However, some people may use this concept as justification for not taking responsibility to make changes: “I am fine just the way I am.” Or, they may focus on only a very specific aspect of a cognitive belief without considering the complexity of the situation. For instance, if I tell a woman “Certainly, you have the right to expect your husband to help with half the housework, but all rights come with consequences and you also need to consider the consequences of that demand and determine how it affects your marriage” I might soon hear from her husband saying that his wife told him that he should help with half the housework! She ignored the rest of the challenge to her thinking.
My point here is that CBT shouldn't be used as a justification for behavior that is unhealthy or inappropriate. It is meant to help a person examine thoughts and choices so as to improve satisfaction with life and with relationships. It is not meant to help a person to continue problematic behaviors. So even if the words are the same, it may not always mean the same thing. You need to look at the underlying meaning as well. In other words, a “should” is not always a “should.” And to paraphrase Freud*, “Sometimes a should is just a should (and nothing else).”
Another frequent error is the tendency to place expectations or demands on the practice of mindfulness. The problem with this is that demands prevent the experience of mindfulness so the more we try to be mindful the less we are able to be mindful.
I experienced this years ago as a college student. During a womens' retreat, we were instructed to listen to some music to allow us to experience imagery to develop personal understanding. As I am lying on the mat and trying to allow the music to create images, I became very frustrated. I thought “I'm not having any images! Nothing is occurring! Everyone else is going to experience something and share what they are experiencing. And I have nothing! How embarrassing! This is a waste of time.”
As you can see, I was not mindful at all. Of course no images occurred. I was so caught up in my (irrational) thinking that I couldn't be mindful. Finally, in frustration, I gave up. I said to myself “I don't care! I'm just going to listen to the music and not worry about trying to have any images.”
As I continued to listen to the music and let all my thoughts drift away, I suddenly had one of the most powerful images that has guided my life to this day. More importantly, I learned the critical concept of not trying to be mindful. Instead of trying to be mindful, learn to allow yourself to be mindful. The more you remove the demand of mindfulness, the more you will achieve it.
* Sigmund Freud, the father of psychoanalysis, who tended to analyze the meaning of everything, has been attributed to say “Sometimes a cigar is just a cigar.”