Cognitive Behavioral Therapy (CBT) in San Diego, CA

CBT is based on the three component model, which is the premise that emotional experiences include thoughts, feelings, and behaviors. Each of these components reciprocally interact and influence one another, creating either helpful or unhelpful feedback loops. Often, we are inclined to notice our uncomfortable or painful emotions, and focus our efforts to change how we feel. However, attempting to control or change our feelings is often ineffective as this is the domain over which we have the least amount of control. Our control efforts often lead to behaviors and patterns of thinking that over time increase our suffering rather than alleviate it.

CBT helps shift our effort to where it is more likely to be effective. The area over which we have the most control is our behavior - that is our actions, what we choose to do or not do. We also have some degree of control over our thoughts. We cannot control automatic thoughts, but we can learn to respond to automatic or unhelpful thoughts with more adaptive thoughts and actions. In focusing our change efforts on our actions and our mindset, we are much more likely to shift the feedback loop in such a way that ultimately helps shift our painful emotions, thus decreasing our overall suffering.

“Cognitive” in CBT refers to our thoughts. We are constantly experiencing the world and interpreting it in our minds. Our thoughts can be helpful, but they can also be unhelpful or maladaptive. One component of CBT is beginning to pay attention to our thoughts and the ways in which we are interpreting our experiences. CBT involves developing an understanding of patterns of thinking we may be prone to which are ultimately contributing to our suffering. These patterns are referred to as cognitive distortions. CBT helps us begin to notice distortions, and instead turn towards more balanced or accurate ways of viewing things in such a way that allows us to respond more effectively. We can challenge thoughts in multiple ways, but one of the most powerful ways is often through experience.

Feelings refer to both emotions and sensations. Typically feelings are one word: afraid, anxious, tense, sad, angry, hurt, nauseous, sweaty, happy, grateful, calm, etc. Feelings are temporary, and come and go when they are given the space to do so. When we wrestle with painful emotions by ruminating or trying to avoid or squelch them, often they persist in increased intensity and duration.

Behaviors are our actions. What we do or do not do. Often, when we are experiencing a painful feeling, we attempt to control it with our behavior. We may engage in various avoidance strategies to try to get rid of our pain. Often, these avoidance strategies bring us much desired relief in the short term, but end up increasing our suffering in the long term. Anxiety and related disorders in particular are fueled by avoidance strategies that prevent us from facing our fears and learning that we are both safer and more capable than we believe. CBT seeks to help us identify the behaviors we engage in that may be increasing our suffering in the long term, and learn instead how to respond with actions that will help us manage our emotions and move through the world more effectively.

Here is an applied example for a client who experiences panic disorder (fear of panic attacks):

Feeling: increased heart rate

Thought: “why is my heart racing?”

Behavior: checks heart rate on Apple Watch

Thought: “That number is too high. Something must be wrong.”

Feeling: fear, anxiety, heart rate further increases, palms begin sweating

Thought: “what if I’m having a heart attack?”

Behavior: Googles heart attack symptoms, sees chest tightness and nausea, scans body for these symptoms

Feeling: increasing fear and anxiety, increased heart rate, tension in chest, slight nausea/dizziness, full body sweating, trembling

Thoughts: “what if I’m dying?”

Behavior: rushes to urgent care for cardiac workup

Outcome: Patient is told they are having a panic attack, and that cardiac issues have been ruled out. Patient is reassured temporarily, but finds himself increasingly vigilant about his physical sensations and begins to treat any sensation that could arise in panic as a medical emergency, keeping him stuck in a vicious cycle of monitoring for, experiencing, and responding to panic related sensations, and avoiding situations he fears may elicit these sensations. He begins to experience them with increased frequency and intensity and finds the situations he must avoid to avoid these symptoms continue to grow over time, limiting his life significantly.

CBT begins with a diagnostic assessment to thoroughly and accurately understand the symptoms and presenting concerns bringing the client to therapy. Diagnostic impressions are then shared with the client, and psychoeducation is provided regarding CBT, the three component model, and how CBT might help alleviate the client’s symptoms. Next, the therapist helps the client understand the various thoughts, feelings, and behaviors that may be part of and/or contributing to her symptoms. Active treatment involves identifying how to help client change behavioral patterns that are worsening symptoms (for both anxiety and depression, unhelpful behaviors often involve avoidance of discomfort), as well as how to alter mistaken or unhelpful patterns of thinking. Interventions are tailored to the particular client, her history, her symptoms and diagnosis, and her goals for therapy.

Using the example client with panic disorder above, a CBT treatment plan might look something like this. A CBT therapist would first help this client identify the cycle that has become cemented in place, and help him understand the role his thoughts and behaviors have in perpetuating his feelings of panic and anxiety. Then treatment would involve psychoeducation helping him understand what is occurring during panic and why, challenging inaccurate beliefs he may have about what is occurring physiologically and the consequences or meaning behind his feelings. Finally, treatment involves exposure work helping the patient to begin to encounter the sensations he fears and rather than avoid or control them, learn to accept and allow them. In so doing, the client begins to learn that his fears (“I’m dying or experiencing an emergency”) are extremely unlikely and that he is more capable of handling these feelings and facing the situations that trigger them than he previously believed. His experiences resulting from his changed behavior begin to change his thoughts, and he no longer finds himself so stuck in this cycle. Over time, as he stops responding with panicked thoughts and behaviors to his anxiety, he finds that the frequency, duration, and intensity of his feelings decreases. Most importantly, he has increased confidence in his ability to handle discomfort and choose for himself how he goes about his life.

CBT is a well established evidence-based treatment with a wealth of research supporting its efficacy in the treatment of a number of psychological conditions. CBT is particularly helpful for clients experiencing anxiety and depression. CBT for anxiety disorders often involves utilizing exposures (helping clients face their fears), while CBT for depression often involves Behavioral Activation (scheduling reinforcing activities that clients commit to following through on regardless of motivation in the moment). A core component of CBT is challenging unhelpful patterns of thinking, but a comprehensive CBT treatment plan should also address the behavioral component of a client’s experience.

My approach to therapy is warm, collaborative, compassionate, and flexible. I know from both my lived and professional experiences that a particular client’s experience cannot be simplified into a one-size-fits-all approach. Symptoms do not always present neatly into one diagnostic category, and a rigid adherence to a manualized treatment protocol may not be effective for everyone. You know yourself and your experience best, and my job is to get curious with you about what is keeping you stuck, what you find most painful and challenging, and what based on my clinical expertise and the best available research is likely to be most effective in not only alleviating your suffering but helping you move toward a life where you are thriving. Your job is to come ready to share your authentic experience, and my job is to have a nuanced and deep understanding of the processes underlying the modalities we know tend to be effective (e.g. CBT, ACT, ERP) and help you learn to apply these processes to your particular pain.