“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 of someone 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.

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.