I often wonder if I would have met my dad’s dad, had better treatments for depression and post-traumatic stress disorder (PTSD) been available after World War II. Frank Gillihan served his country in the Pacific theater and carried home the horrors he witnessed there. Fifty years ago this month he chose to end his life.
Around the time of my grandfather’s death, powerful treatments were being developed that would change—even save—countless lives. Psychologist Albert Ellis and psychiatrist Aaron Beck each noted how thoughts can drive our emotions, and that certain thinking patterns create suffering. For example, depression is linked to thoughts like “I’m such a loser” or “I deserve to be punished.” These developers of Cognitive Therapy also recognized that more adaptive ways of thinking have the power to heal.
Around the same time, people like Joseph Wolpe and Arnold Lazarus were developing a behavior-focused therapy. They found that making straightforward behavior changes could lead to major improvements in a wide range of psychological conditions. For example, by gradually approaching what we’re afraid of, we can conquer phobias and other fear-based conditions.
It was only a matter of time before these two streams merged into what is today called Cognitive Behavioral Therapy (CBT). CBT is based on the connections among thoughts, feelings, and behaviors, as shown in the figure.
In depression, for example, we feel very low, think depressing thoughts, and withdraw from rewarding activities. Each of these elements will reinforce the others, creating a downward spiral that’s hard to escape.
Through CBT we can change our thoughts and behaviors to break out of this spiral. Highly effective CBT treatment programs have been developed for many conditions, including depression, anxiety, and PTSD.
What Makes CBT Special?
While CBT is relatively new, the principles it’s based on are not. Nearly 2000 years ago the Greek philosopher Epictetus summarized the core of cognitive therapy when he wrote,
People are not disturbed by things but by the view they take of them.
We’ve also known for ages that the best way to overcome our fears is to face them.
So what’s the big deal about CBT if its basic tenets are nothing new?
It’s one thing to know what we need to do to feel well, and quite another thing to actually do it. For example, how many of us struggle to exercise consistently even though we know it’s good for us? Just as an exercise program turns knowledge about the benefits of exercise into action, you can think of CBT as an exercise program for the brain: By putting basic cognitive and behavioral principles into a structured and systematic format, CBT provides the necessary regimen to develop new habits.
Setting Goals That Compel Us to Action
CBT starts with taking a good look at our lives—relationships, work, education, hobbies, exercise, spirituality—to determine what’s going well and what’s not. Based on this assessment we can formulate goals, which provide a clear and empowering vision of where we want to go.
Effective goals are specific enough that we’ll know when we’ve reached them and are appropriately difficult—too easy and we’ll be uninspired, too difficult and we’ll feel overwhelmed. They also have to be our own, rather than what we imagine someone else wants for us.
Once we know what our goals are, we can put together a treatment plan, which will vary depending on the condition.
Three Major Treatment Approaches of CBT
Below I describe some of the major treatment approaches in CBT, drawing from my workbook for managing depression and anxiety (Cognitive Behavioral Therapy in 7 Weeks).
Getting Back to Life
When we’re depressed and anxious we’re prone to withdraw from life, which can lead to a vicious circle—as our world shrinks, we feel more anxious and depressed, making us more inclined to withdraw. A type of CBT called Behavioral Activation helps us return to life-giving activities. It’s a good approach to start with when we’re depressed because it’s straightforward and highly effective.
In Behavioral Activation we identify what’s important to us in different areas of our lives—for example, maybe we love spending time outside. We then make a list of activities that would nourish us in those areas, like planting spring flowers. Each week we choose activities from the list, planning specific times to complete them to maximize follow-through.
Since motivation is low when we’re depressed, the treatment emphasizes ways to make it easier:
- Start with less difficult activities.
- Break tasks into manageable chunks.
- Schedule specific activities and build in accountability.
Small changes over time can lead us back to a life we’re excited to live.
Breaking Negative Thought Patterns
Simply knowing our thoughts aren’t serving us well is rarely enough to help us change them. We might just start feeling bad about having unhelpful thoughts! As with Behavioral Activation, Cognitive Therapy takes a structured approach to create real change.
We begin by identifying our thoughts since we often don’t even realize what we’re telling ourselves. For example, we might notice that when we make a mistake we say, “I can’t do anything right.”
We then work with the therapist to examine our thought patterns, systematically replacing biased and unhelpful thoughts with more accurate and friendly ones. Through practice and repetition, we can develop habits of thought that serve us well.
Facing Your Fears
When we’re battling anxiety conditions like a phobia or panic disorder, we often avoid what we’re afraid of.
A type of CBT called exposure therapy helps us approach what we fear, starting with less terrifying activities and gradually working up to harder ones. Over time, exposure rewires our brains to be less afraid through the process of neuroplasticity.
Exposure is also a crucial part of most CBT programs for PTSD. Years ago I coordinated a PTSD treatment study and worked with several veterans who carried as many emotional scars as physical ones. While no one can ever unring the bell of combat, the majority of veterans who complete CBT get relief not only from their PTSD but also from depression. I often thought back to my grandfather and countless individuals like him for whom these treatments came too late.
Finding a CBT Therapist
Despite the advent of new and better therapies, many people still don’t have access to treatment. Perhaps they don’t live close to a CBT therapist, or can’t afford it. Others simply don’t know about CBT.
If you’re interested in CBT for anxiety or depression but aren’t able to see a CBT therapist, take heart—you may not need to. There are multiple options for doing CBT without a therapist, including self-help books and Internet-based treatment. Many studies have shown that self-directed CBT can lead to long-lasting improvements in both anxiety and depression.
Once you learn the skills of CBT, they’re yours, available whenever you need them.
Self-help CBT is probably best for a person with mild to moderate anxiety or depression. Someone who is severely depressed will likely need one-on-one treatment with a professional.
If you’re interested in self-directed CBT, the Association for Behavioral and Cognitive Therapies maintains a list of books with their “seal of merit.” My CBT workbook for managing anxiety and depression is available from Amazon. It’s dedicated to my grandfather.
Seth J. Gillihan, PhD, is a clinical assistant professor of psychology in the psychiatry department at the University of Pennsylvania Perelman School of Medicine. He is the author of Retrain Your Brain: Cognitive Behavioral Therapy in 7 Weeks and co-authored Overcoming OCD: A Journey to Recovery with Janet Singer. Dr. Gillihan blogs on Psychology Today and his website. His clinical practice is in Haverford, PA, where he specializes in the treatment of anxiety, depression, PTSD, and related conditions.