Introduction to Cognitive Behavioral Therapy

By Nelson Binggeli, PhD

The principles and methods of Cognitive Behavioral Therapy (CBT) are among the primary ways that I help my clients achieve their goals for positive change in their lives. Because CBT is a very collaborative form of therapy, I believe it is helpful for my clients to understand these principles and methods. Ultimately, I would like for my clients to become skilled in using CBT on their own to meet the challenges in their lives, long after their work with me has ended. Prior to reading this material, please read mydisclaimerregarding information provided on this website.

An overview of CBT

CBT is a form of psychotherapy that has been demonstrated to be effective in helping to people to overcome a wide variety of problems, including those involving depression and anxiety. It is based upon scientifically-informed principles of human psychology and its effectiveness for many problems has been supported by hundreds of scientific studies. CBT focuses on the patterns of thought and behavior that maintain both adaptive and maladaptive behavior. It assumes that these patterns are learned, and that new patterns can be learned when old ones are no longer useful.

CBT tends to be a present-centered, active, collaborative, and short-term form of therapy. Although therapists do not disregard how problems may have developed (e.g., as a result of childhood experiences), their primary focus is on helping the client identify and change what is maintaining the problem in the present. The relationship between the therapist and the client is marked by collaboration, and clients are encouraged to take an active role in applying the techniques both within and between therapy sessions. Therapy tends to be short-term (often between 5-30 sessions over a period of one to 18 months), and emphasizes the client learning principles and techniques that will serve them long after their work with the therapist has ended.

Cognitive aspects of CBT

Cognition can be defined as the mental processes of perceiving, remembering, reasoning, evaluating, and imagining. CBT holds that most of our emotions and behaviors are the result of our cognitions regarding what we think or believe about ourselves, other people, and the world. These cognitions shape how we interpret and evaluate what happens to us, influence how we feel about it, and provide a guide to how we should respond. Unfortunately, sometimes our interpretations, evaluations, and underlying beliefs thoughts contain distortions, errors, or biases, or are not very useful or helpful. This results in unnecessary suffering and often causes us to react in ways that are maladaptive. CBT provides many methods for becoming more aware of our cognitions and for modifying them when they are distorted or are not useful. Collectively, these methods are called cognitive restructuring.

Behavioral aspects of CBT

The behavioral aspects of CBT emphasize the role of what we do (i.e., our behavior) in shaping how we feel, what we believe, and how we behave in the future. In CBT, the therapist helps the client to identify which behaviors are likely maintaining the problem, and which behaviors are likely to help produce positive changes. Often, problems are the maintained by avoidance, either of actual situations or of internal experiences (such as emotions and memories). This prevents new learning that potentially could disprove distorted negative beliefs about oneself, others, and the world, and keeps people stuck in old maladaptive patterns. It also prevents people from experiencing positive reinforcement that provides satisfaction and motivation. In CBT, the therapist and client collaborate in choosing new behaviors for the client to engage in that help the client to gradually overcome this avoidance.

The behavioral aspects of CBT are guided by scientifically-based principles of learning derived from over a century of research on animal and human behavior (such asclassicalandoperantconditioning).

Techniques of CBT

The following are some of the primary techniques used in CBT. More information about each technique can be found by clicking on the name of the technique.

(1)Promoting more accurate and useful thinking (cognitive restructuring): A key component of CBT is called cognitive restructuring, which is a set of procedures that promote more accurate and useful thinking. It is very helpful in treating depression, anxiety, and other problems.

(2)Increasing rewarding activity (behavioral activation): Depression often leads to withdrawal, avoidance, and inactivity. This prevents people from having positive experiences that are satisfying and motivating. Through a set of techniques called behavioral activation, CBT helps people to identify and engage in activities that increase the chance they will have rewarding experiences.

(3)Overcoming anxiety by facing fears (exposure therapy): Anxiety disorders are maintained by avoidance. CBT helps people overcome anxiety by facing their fears in a systematic way called exposure therapy.

(4) Learning new skills (skills training): Sometimes people avoid certain situations because they perceive they lack the skills to manage them. Accordingly, CBT also often includes learning new behavioral skills, such asassertive communication skillsto deal with social situations andrelaxation skillsto deal with anxiety.

A very brief history of CBT

CBT is actually a merger of many different theories and streams of research. The cognitive aspects have their roots partly in the work of psychoanalysts who broke with Sigmund Freud, such asAlfred Adler, and partly in theStoic philosophersof ancient Greece who were introduced to psychology byAlbert Ellis. Ellis may be considered the first psychologist that produced a fully-formed version of cognitive therapy beginning in the 1950s (now calledRational Emotive Behavioral Therapy).Aaron Beckalso developed somewhat similar form of cognitive therapy beginning in the 1960s. Becks version forms the basis of the most widely researched and practiced form of cognitive therapy today (and is the form that I practice). The behavioral aspects of CBT have their roots in thebehavioristtradition of psychology, particularly influenced by the research ofIvan PavlovandJohn B. Watsonearly in the 20th century andB. F. Skinnerin the mid-20th century. An important early behavioral therapist wasJoseph Wolpe. An important theorist and researcher who helped to bridge the gap between the cognitive and the behavioral isAlbert Bandura. There are many more important theorists and researchers that this brief history necessarily omits.

For further reading

More information about CBT can be found on the websites of the following professional organizations:

Academy of Cognitive Therapy

Association for Behavioral & Cognitive Therapies

Beck Institute for Cognitive Therapy & Research

National Association of Cognitive Behavioral Therapists

An article describing CBTby Ben Martin, PsyD on PsychCentral.com

Research supporting CBT

Butler AC, Chapman JE, Forman EM, & Beck AT. (2006).The empirical status of cognitive-behavioral therapy: a review of meta-analyses.Clinical Psychology Review, 26, 1, 17-31.

Hollon, S. D., Stewart, M. O., & Strunk, D. (2006).Enduring effects for cognitive

behavior therapy in the treatment of depression and anxiety.Annual Review ofPsychology, 57, 285315.

Olatunji BO, Cisler JM, Deacon BJ. (2010).Efficacy of cognitive behavioral therapy for anxiety disorders: a review of meta-analytic findings.Psychiatric Clinics of North America, 33, 3, 557-77.

The Society of Clinical Psychology (a division of the American Psychological Association) provides a summary ofResearch Supported Psychological Treatments, many of which are based on CBT.--Last updated: 02.05.10--Navigation:Home>Resources>Coping skills & treatments> Cognitive Behavioral TherapyCBT techniques, part 1: Cognitive restructuring

By Nelson Binggeli, PhD

Introduction

This is the first in a series of three articles describing the primary techniques of Cognitive Behavioral Therapy (CBT). Prior to reading this article, please read myIntroduction to CBTand mydisclaimerregarding information provided on this website.

This article focuses on a set of techniques called cognitive restructuring, which help to to promote more accurate and useful thinking. It is very helpful in treating depression, anxiety, and other problems.

An overview of cognitive restructuring

CBT holds that most of our emotions and behaviors are the result of what we think or believe about ourselves, other people, and the world. These cognitions shape how we interpret and evaluate what happens to us, influence how we feel about it, and provide a guide to how we should respond. Unfortunately, sometimes our interpretations, evaluations, and underlying beliefs thoughts contain distortions, errors, or biases, or are not very useful or helpful. This results in unnecessary suffering and often causes us to react in ways that are not in our best interest.

Cognitive restructuring is a set of techniques for becoming more aware of our thoughts and for modifying them when they are distorted or are not useful. This approach does not involve distorting reality in a positive direction or attempting to believe the unbelievable. Rather, it uses reason and evidence to replace distorted thought patterns with more accurate, believable, and functional ones.

An illustration

To illustrate the role of thoughts in influencing emotions and behavior, consider the following vignette1: Suppose you are at a party and have been introduced to Alex (you can imagine Alex as a male or as a female). As you talk, Alex never looks at you; in fact, throughout your brief conversation s/he looks over your shoulder across the room. What are you thinking and feeling, and how would you respond?

This is deliberately an ambiguous situation that can be interpreted in many ways, because much of life is like this. We often have to make sense of what is happening to us based upon limited information. Lets consider how three different people interpreted and reacted to this scenario:

Person A thought Alex is rude. S/he is insulting me by ignoring me. As a result, they felt annoyed and they terminated the conversation and avoided Alex at future parties. Person B thought Alex doesnt find me interesting. I bore everybody. As a result, they felt ashamed and depressed, and they left the party and became more likely to decline invitations to parties in the future. Person C thought Alex seems shy. S/hes probably to uncomfortable to look at me. As a result, they felt sympathetic and attempted to engage Alex in a conversation about how Alex knew the host of the party.

This vignette illustrates that given the same situation, people can have very different interpretations and reactions. Often these are indicative of recurrent patterns of thought and underlying beliefs. CBT holds that when we are experiencing problems in our lives, it can be very helpful to become aware of these patterns and beliefs and to be curious about how accurate and useful they are.

The cognitive (ABC) model

Albert Ellis, one of the pioneers of CBT, illustrated how our emotions and behaviors are often the result of what we think or believe with his ABC model. In the model, A stands for the event or situation that triggers a cognitive, emotional, and behavioral reaction. B stands for our underlying beliefs about ourselves, other people, and the world and the resulting interpretations and evaluations we make of the event or situation. C stands for the consequence of our interpretations and evaluations which can include both an emotional reaction and a behavioral response. To show how the model works, I have used the experience of Person B from the vignette above.

Cognitive distortions

The term cognitive distortion refers to errors in thinking or patterns of thought that are biased in some way. They may include: (A) interpretations that are not very accurate and which selectively filter the available evidence, (B) evaluations that are harsh and unfair, and/or (C) expectations for oneself and for others that are rigid and unreasonable. The more a persons thinking is characterized by these distortions, the more they are likely to experience disturbing emotions and to engage in maladaptive behavior. A number of common patterns2of cognitive distortions have been identified, including:

1. All-or-nothing thinking: Looking at things in absolute, black-and-white categories, instead of on a continuum. For example, if something is less than perfect, one sees it as a total failure.

2. Overgeneralization: Viewing a negative event as a part of a never-ending pattern of negativity while ignoring evidence to the contrary. You can often tell if youre overgeneralizing if you use words such as never, always, all, every, none, no one, nobody, or everyone.

3. Mental filter: Focusing on a single negative detail and dwelling it on it exclusively until ones vision of reality becomes darkened.

4. Magnification or minimization (e.g., magnifying the negative and minimizing the positive): Exaggerating the importance of ones problems and shortcomings. A form of this is called catastrophizing in which one tells oneself that an undesirable situation is unbearable, when it is really just uncomfortable or inconvenient.

5. Discounting the positive: Telling oneself that ones positive experiences, deeds, or personal qualities dont count in order to maintain a negative belief about oneself. Or doing this to someone else.

6. Mind reading: Concluding what someone is thinking without any evidence, not considering other possibilities, and making no effort to check it out.

7. Fortune telling: Anticipating that things will turn out badly, and feeling convinced that the prediction is an already established fact. It often involves: (A) overestimating the probability of danger, (B) exaggerating the severity of the consequences should the feared event occur, and (C) underestimating ones ability to cope should the event occur. B and C are also examples of catastrophizing.

8. Emotional reasoning: Assuming that ones negative emotions necessarily reflect the way things really are (e.g., Because I feel it, it must be true. I feel stupid, therefore I am stupid).

9. Rigid rules (perfectionism). Having a precise, fixed idea of how oneself or others should behave, and overestimating how bad it is when these expectations are not met. Often phrased as "should" or must statements.

10. Unfair judgments: Holding oneself personally responsible for events that aren't (or arent entirely) under ones control, or blaming other people and overlooking ways in which one might have also contributed to the problem.

11. Name-calling: Putting an extremely negative and emotionally-loaded label on oneself or others. It is an extreme form of magnification and minimization, and also represents a gross overgeneralization.

In addition to the above list which is largely influenced byAaron Becksversion of cognitive therapy,Albert Ellisproduced a similar list that highlights what he calledirrational beliefs(which consist of faulty assumptions and unreasonable rules about life).

The origin and function of cognitive distortions

Where do these distortions come from, and what purpose do they serve? Frequently, cognitive distortions develop in childhood as the result of unfortunate and difficult life experiences and/or being taught to use them by significant others (e.g., parents and peers). We also become more prone to cognitive distortions when under stress, because under pressure we are apt to take more cognitive shortcuts resulting in less accurate and more extreme interpretations and reactions. Cognitive distortions can also serve the function of trying to protect us from harm. For example, when a depressed or anxious person thinks, I cant do it, it justifies inaction and protects the person from possible failure. Of course, this strategy is ultimately self-limiting and defeating, and keeps people stuck in old patterns that dont work very well.

How CBT views emotions

CBT is not saying that all negative or painful emotions are bad and that we should always think positively. Emotions such as fear, anger, and sadness can be very appropriate and even useful. Fear can tell us there is danger, and motivate us to protect ourselves. Anger can inform us that our rights are being violated, and we need to take action to assert our rights. Sadness can be the result of losing something or someone important to us, and can indicate that we need to take the time to grieve.

What is important is not whether an emotion is positive or negative, but whether it is adaptive or maladaptive. Negative and painful emotions can be adaptive if they are based on accurate thinking and guide an appropriate response. Maladaptive emotions are driven by distorted thinking and cause unnecessary suffering and inappropriate responses. One way of defining mental health might be the extent to which one can recognize the difference between adaptive or maladaptive emotions.

The process of cognitive restructuring

Cognitive restructuring refers to the process of replacing cognitive distortions with thoughts that are more accurate and useful. Cognitive restructuring has two basic steps: (1) Identifying the thoughts or beliefs that are influencing the disturbing emotion; (2) Evaluating them for their accuracy and usefulness using logic and evidence, and if warranted, modifying or replacing the thoughts with ones that are more accurate and useful.

In CBT, the therapist guides the client through the process of becoming more aware of what they are telling themselves and helps them to evaluate, and when appropriate, to modify their own thinking. In essence, the therapist teaches the client a process that will help them distinguish distorted thinking from more accurate and useful thinking. CBT emphasizes that this is best done as a collaborative process in which the client is assisted in taking the lead as much as possible. The therapist refrains from assuming that the clients thoughts are distorted and instead attempts to guide the client with questions that encourage the client to make their own discoveries. Clients are also encouraged to engage in his process on their own during their time between sessions by using a written format, described below.

The Cognitive Restructuring Worksheet

When learning Cognitive Restructuring, it is very helpful to use a worksheet designed to guide the process. I encourage you to download theCognitive Restructuring Worksheet(which is in Microsoft Word format) to have available as you read the next section. Having it in this format allows you to print multiple copies, or to type directly onto it. The table below depicts the main headings of the worksheet.

The following are instructions regarding how to use this worksheet. Below these instructions is an example of a completed Cognitive Restructuring Worksheet.

Part I: Identifying emotion-causing thoughts

Instructions: When you are experiencing a negative emotion use the following procedures to identify the emotion-causing thoughts.

1.Situation: Briefly describe the situation that led to the emotions.

2. Emotions / ratings: Identify the emotions you are experiencing and any physical sensations. Emotions can be described by single words, such as sad, nervous, afraid, angry, guilty, or ashamed. For more examples of emotion words,click here. Then, rate the intensity of your emotions using the scale below.

3. Automatic thoughts / ratings: Identify the thoughts or images connected to the emotions and record them in brief simple declarative sentences or statements. For examples, see the completed worksheet below. (These thoughts are called automatic because they tend to occur automatically or habitually). Questions3that may help you to identify thoughts are:

1. What is going through my mind as I am feeling this emotion?2. What am I telling myself about this situation?3. What am I afraid might happen?

Once you identify a thought, you can further explore the meaning of the thought to you and record these thoughts. Questions that may be helpful are:

1. If this thought is true, what does this say about me as a person?2. What does it say about my life, and my future?3. What is the worst thing that could happen if it is true?4. What does this mean about how other people think about me?5. What does this mean about how I think of other people?6. What images or memories do I have in this situation?

Once you have identified a number of thoughts, put a star by one or two of the thoughts that seem to be producing the most emotion (hot thoughts). Then, rate your degree of belief that each hot thought is true (0-100%).

Part II: Evaluating and modifying thoughts

The second part of cognitive restructuring involves evaluating your automatic thoughts and perhaps developing a new perspective that is more accurate and useful.

Instructions: Choose one or more hot thoughts to work on. It is best to focus on only one or two of these thoughts at a time.

1. Identify any cognitive distortions: Identify if the thought contains any cognitive distortions (refer to the list of common cognitive distortions).

2. Evaluate and modify: Evaluate the accuracy and usefulness of the thoughts, and if warranted, modify the thoughts in a more accurate and useful direction.

Some questions3can help you evaluate theaccuracyof a thought:

1. What is the evidence that supports or contradicts this thought?2. Is there an alternative explanation? Is there another way of looking at it?3. Am I overestimating the probability of the negative event occurring? What is the worst that could happen? What is most realistic?4. Am I overestimating the severity of the consequences of the event (should it occur)? Is it really a terrible catastrophe if X happens? Could I cope with it?5. Does X have to = Y (e.g., Does not having a dating partner = being a loser?)6. If a friend had this thought, what would I tell them?

Some questions can help you evaluate theusefulnessof a thought:

1. What are the advantages of telling myself this? And what are the disadvantages?2. What might be a more useful or helpful way of thinking about this?3. To the degree that this belief is true, what should I do about it?4. 5. Be sure to record any data that contradicts the thought, and the more rational thoughts you may have composed.

3. Summarize your new perspective: Summarize or highlight the key points you discovered as a result of the work you have done.

4. Go back and re-rate your degree of belief in the hot thoughts and the intensity of your original emotions. Note whether there has been a change in your emotions.

Example of a completed Cognitive Restructuring Worksheet

The following is an example of a worksheet completed by a semi-fictional 20 year-old male college student.4 He has come to counseling to get help with his depression, low self-esteem, and social anxiety (e.g., fear of being judged negatively by others). In particular, he is unhappy because he has never had a girlfriend. This is largely because he has never initiated relationships with females because he sees himself as undesirable and likely to be rejected. The thought of initiating a relationship makes him very anxious. In actuality, he is handsome, smart, personable, and caring toward others. However, like many people with low self-esteem and depression, he cannot see these positive characteristics in himself. In this example, I selected two of his upsetting thoughts, identified some of the his primary emotions, and then evaluated and modified his thoughts using the procedures described above.

Comments: His original automatic thoughts were marked by cognitive distortions that selectively filtered the evidence (e.g., ignoring evidence contrary to the idea that he is undesirable) and faulty reasoning (e.g., not having a girlfriend must necessarily mean that he is undesirable). It was distorted thinking like this that produced his social anxiety in the first place earlier in his teens. In turn, the anxiety inhibited him from pursuing relationships with females. As a result, he felt even more unwanted and undesirable. Notice how a self-reinforcing vicious cycle tends to develop between negative distorted thoughts and avoidance behaviors. This cycle is what is behind many peoples problems with depression and anxiety.

Troubleshooting cognitive restructuring

Frequently, people say that they have completed the cognitive restructuring process and they know that their thinking is distorted but they still feel that it is true. When this occurs, they may be tempted to conclude that cognitive restructuring isnt very helpful. However, there are a number of reasons that this might occur:

1. Failing to fully identify the thoughts driving the emotions (including interpretations, evaluations, and underlying expectations). It can be helpful to explicitly answer all of relevant questions in Part I in writing.

2. Failing to fully challenge and modify the thoughts. Often people stop once they see their thoughts are distorted, but do not specifically identify what makes them distorted or come up with alternative ways of thinking. It can be helpful to explicitly answer all of relevant questions in Part II in writing, and then to write out a summary of the alternative way of thinking.

3. The distorted thoughts serve a purpose, and people can be reluctant to let this go. Remember that distorted thoughts often are an attempt to protect a person from negative consequences. It can be helpful to ask, What are the advantages and disadvantages of believing this thought? Often, there are some advantages, but they are frequently outweighed by the disadvantages.

4. Often cognitive restructuring is not enough on its own, and a person needs new learning experiences to convince them of what is true at a deeper level. This means engaging in new behaviors, often of the type that the person has been avoiding due to pessimism or anxiety. This can be where CBT techniques such asbehavioral activation(for depression) andexposure(for anxiety) can be very helpful.

5. Finally, it is helpful to remember that it may have taken a lifetime to develop these patterns of thought, and takes time and hard work to change them.

More about Cognitive Behavioral Therapy (CBT)

An Introduction to Cognitive-Behavioral Therapy (CBT) CBT techniques part 1: Cognitive restructuring (you are on this page) CBT techniques part 2:Behavioral activation CBT techniques part 3:Exposure therapy

Notes

1. This vignette was adapted from:Mind over mood- Change how you feel by changing the way you think, by Dennis Greenberger & Christine Padesky.

2. This list of cognitive distortions was partially adapted from:The feeling good handbook, byDavid Burns. Plume, 1999.

3. These lists of questions were adapted from:Cognitive therapy: Basics & beyond, byJudith Beck.

4. This semi-fictional male college student is a representative composite of several clients I have worked with over the years.--Last updated: 02.05.10--Navigation:Home>Resources>Coping skills & treatments>Cognitive Behavioral Therapy> Cognitive restructuring

CBT techniques, part 2: Behavioral activation

Introduction

This is the second in a series of four articles describing the primary techniques of Cognitive Behavioral Therapy (CBT). Prior to reading this article, please read myIntroduction to CBTand mydisclaimerregarding information provided on this website.

This article focuses on a set of techniques called behavioral activation, which involve helping people to identify and engage in activities that increase the chances they will have rewarding experiences. It is very useful in the treatment of depression.

An overview of behavioral activation

Depression often leads to withdrawal, avoidance, and inactivity. This prevents people from experiencing positive reinforcement that provides satisfaction and motivation. While it is understandable that people withdraw when they arent feeling well and avoid what they are afraid of, ultimately this is detrimental to well-being and it can become an ingrained habit. Behavioral activation is a set of techniques for helping people to overcome this habit. Therapists help their clients to set weekly goals, to identify possible sources of positive reinforcement, and to schedule and structure their activities.

I plan to write a more detailed guide to the specific techniques of behavioral activation. Until then, you can read more about it by exploring the links provided below.

Online resources regarding behavioral activation

Wikipedia(Behavioral Activation)

Derek Hopko, PhD(behavioral activation researcher)

Christopher Martell, PhD(behavioral activation researcher)

The Society of Clinical Psychology

PDFs available from theCentre for Clinical Interventions Depression Resources):An overview of behavioral activation;Fun activities catalog;Behavioral activation worksheet

Book recommendation

An excellent book for the general public is:Overcoming depression one step at a time: The new behavioral activation approach to getting your life back, by Michael E. Addis & Christopher R. Martell. New Harbinger, 2004.

Selected research

Cuijpers P, van Straten A, Warmerdam L. (2007).Behavioral activation treatments of depression: a meta-analysis.Clinical Psychology Review, 27, 318326.

Dobson KS, Hollon SD, Dimidjian S, Schmaling KB, Kohlenberg RJ, Gallop RJ, Rizvi SL, Gollan JK, Dunner DL, Jacobson NS. (2008).Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression.Journal of Consulting & Clinical Psychology, 76, 468477

More about Cognitive Behavioral Therapy (CBT)

An Introduction to Cognitive-Behavioral Therapy (CBT) CBT techniques part 1:Cognitive restructuring CBT techniques part 2: Behavioral activation (you are on this page) CBT techniques part 3:Exposure therapy

Disclaimers

Please see mydisclaimersregarding the information provided on this website, the links to external information, and my lists of possible referrals.--Last updated 02.05.11--Navigation:Home>Resources>Coping skills & treatments>Cognitive Behavioral Therapy> Behavioral activation

CBT techniques, part 3: Exposure therapy

By Nelson Binggeli, PhD

Introduction

This is the third in a series of four articles describing the primary techniques of Cognitive Behavioral Therapy (CBT). Prior to reading this article, please read myIntroduction to CBTand mydisclaimerregarding information provided on this website.

This article focuses on a set of techniques called exposure therapy, which help people overcome anxiety by learning to face their fears in a systematic way. Exposure therapy been shown to be very effective in treating anxiety disorders, includingGeneralized Anxiety Disorder,Obsessive Compulsive Disorder,Panic Disorder,Posttraumatic Stress Disorder,Social Anxiety Disorder, andSpecific Phobia. This article first describes how anxiety disorders develop at least partially through classical conditioning and avoidance. It then presents the principles of exposure therapy.

Classical conditioning

In order to understand why exposure therapy works, it helps to understand classical conditioning and its role in the anxiety disorders. Classical conditioning was first demonstrated by Ivan Pavlov, a Russian physiologist, in his famous experiments with dogs around the turn of the 20th century. Pavlov showed that if you repeatedly ring a bell right before giving food to a dog, it will eventually come to salivate upon hearing the bell only. The general principle that Pavlov discovered was that if you repeatedly present a stimulus that naturally causes a reaction (e.g., food causing salivation) right after presenting a previously neutral stimulus (i.e., the bell), an animal will come to react to the previous neutral stimulus in a similar way.

Classical conditioning forms part of the basis for anxiety disorders. People with anxiety disorders have come to associate non-threatening neutral stimuli with either traumatic experiences or imagined future catastrophes. They have learned to react to a previously neutral stimulus as if it were an actual threat. For example someone with a phobia of dogs may experience a stress reaction just by looking at a picture of a dog. They may rationally know that the picture cannot hurt them, but nevertheless their brain triggers the release of adrenaline to help their body either fight or flee. This illustrates how classical conditioning is an automatic emotional response that bypasses rational thought.

Classically conditioned responses are recorded deep in the emotional centers of the brain (i.e., the limbic system). When we perceive that something is threatening, our emotional centers send out an alarm. It takes a few more milliseconds for the rational centers of our brain to process what is happening. When we are afraid, our body responds more strongly to the alarm from the emotional centers of the brain than to our rational thoughts. This is responsible for the phenomenon of knowing that something isnt threatening and yet still feeling afraid.

In Panic Disorder, people come to fear body sensations that actually are not harmful. In Generalized Anxiety Disorder, people react to thoughts and images of possible future negative events almost as strongly as if they were actually occurring. In Posttraumatic Stress Disorder, people react to things that remind them of a traumatic event almost as if the event were actually occurring in the present. In Social Anxiety Disorder, people come to associate social situations with visions of being humiliated. In Obsessive Compulsive Disorder, people develop an exaggerated fear of not doing something to remove a possible threat, no matter how unlikely this threat may be.

The role of avoidance

Typically, people tend to avoid these stimuli as much as possible. While this is understandable, it prevents the emotional centers of their brain from learning that these stimuli actually are not threatening. This maintains and may even strengthen the perception that these stimuli are something to be feared. Over time, avoidance behavior can become stronger and more pervasive because it provides relief from anxiety (thought a process called negative reinforcement). Accordingly, in order to overcome anxiety and its limiting effect on ones life, one must learn to stop avoiding.

Exposure therapy

Exposure therapy is a technique for reducing classically conditioned responses. In exposure therapy, clients voluntarily agree to be exposed to the very stimuli that trigger the anxiety response. When people repeatedly expose themselves to stimuli that they fear and nothing bad happens, the emotional centers of the brain learn that they can relax in the presence of this stimuli.

The stimuli may be actual or imagined and it may be confronted in the therapists office or in real life. Often, people find it more acceptable to begin with exposure to imagined objects or events before confronting actual ones. Typically, the exposure exercises begin with stimuli that might arouse only mild to moderate levels of anxiety. After several successful exposures, people often are ready to confront things that are even more anxiety provoking. Often, the therapist helps the client to develop coping strategies for managing the anxiety-provoking situation, which can include relaxation skills, assertive communication skills, and more rational ways of thinking about situation (seecognitive restructuring).

Exposure therapy can be challenging for both clients and for therapists. Confronting stimuli that causes feelings of fear, helplessness, shame, disgust, or horror is not easy. However, there is a lot of scientific evidence that it works, and most people find that ultimately the short-term pain caused by exposure is greatly outweighed by becoming liberated from classically conditioned fear responses. In addition, the graduated nature of the exposures (i.e., starting with less fearful stimuli) and the use of improved coping strategies make it somewhat less challenging than it might otherwise be.

There are several theories about why exposure works. The one that has the most research support is that it works primarily through the mechanism of habituation. Habituation occurs when the repeated exposure to a stimulus decreases our responsiveness to it. For example, we may come to tune out the noise of a loud fan after being in a room with it for a while. It is also possible that we replace one form of conditioning for another (this has been called counterconditioning). Because an anxiety response cannot continue indefinitely, eventually anxiety decreases during exposure. When this happens, the association between the stimulus and the anxiety response is weakened and replaced with an association with a more relaxed state. Theorists who emphasize cognitive factors argue that (a) safe exposure may help people think about the stimuli more objectively, (b) people come to expect that theyll be less anxious in the presence of the stimuli, and (c) exposure may strengthen the persons beliefs that they are capable of coping with their anxiety.

Creating an anxiety hierarchy

The first step in conducting exposure therapy is creating what is called an anxiety hierarchy. This is a list of the stimuli that causes an anxiety reaction arranged in a hierarchy according to how much anxiety each stimuli causes. For example, stimuli that cause only mild anxiety are listed at the bottom of the list.

More specific information about how to create an anxiety hierarchy will be provided here soon.

Conducting exposure exercises

More specific information about this will be provided soon.--Websites for more information

Center for the Treatment and Study of Anxiety, at the University of Pennsylvania, directed by Edna Foa, PhD

More about Cognitive Behavioral Therapy (CBT)

An Introduction to Cognitive-Behavioral Therapy (CBT) CBT techniques part 1:Cognitive restructuring CBT techniques part 2:Behavioral activation CBT techniques part 3: Exposure therapy (you are on this page)--Last updated 02.05.11--Navigation:Home>Resources>Coping skills & treatments>Cognitive Behavioral Therapy> Exposure therapy