So what is Cognitive-Behavioral Therapy (CBT)? It is a type of therapy that seems to work really well for anxiety, depression, and a whole set of other issues. CBT is what I typically employ with my clients, with the addition of hypnosis, which as you'll see fits well into the whole behavioral model. Let's explore some basic concepts of CBT, with a few examples to show you how it works.

Psychotherapy first started to become popular with Freud, a trained neurologist (and hypnotist) who thought that by exploring hidden desires and impulses he could cure people of their mental ailments. There were a few problems with his methods. For one, it was difficult to test to see if it worked. For another, sometimes the analyst's interpretation is as much a reflection of the analyst as the patient! Lastly, it took forever. In the movie "The Sleeper," staring Woody Allen, a man who woke up 200 years in the future remarks, "I haven't seen my analyst in 200 years. He was a strict Freudian. If I'd been going all this time, I'd probably almost be cured by now."

CBT is by and large a departure from the Freudian method of psychotherapy, which itself evolved into psychodynamic modalities.

A man named B. F. Skinner took a much more scientific look at psychotherapy. He started by training animals. He discovered, along with Pavlov, that you can train a dog, a pigeon, or most any other animal to express or repress behaviors based upon rewards and punishments (mostly rewards, punishments don't seem to work that well).

But that's not what made Skinner famous. What got people talking was when he applied these same techniques to humans. Turns out, the same techniques you can use to get rid of a fear of snakes in monkeys you can use to get rid of a fear of snakes in humans. Many people, already befuddled that they apparently evolved from animals, now had to deal with the concept that we very much act and train like them as well.

So you had the Freudian group emphasizing the human nature of people: their thoughts and dreams and fantasies, while the Skinner group --the Behaviorists-- emphasizing how, on many levels, humans are just well shaved apes! This led to them often ignoring those fantasies and dreams and childhood experiences so valued by the Freudians. They would simply train a person much as you would a house pet!

Problem is, the techniques worked. A classic behavioral technique to cure enuresis -- a fancy way of saying bedwetting -- is through a bed wetting alarm. A moisture detector is placed in the child's bed. As soon as moisture is detected, the alarm goes off, the child wakes up, and soon starts to associate the urge to urinate with waking up. Before this concept was developed, it was assumed that childhood bedwetting was a symptom of childhood anxiety. After all, children passed through the Oedipus complex right around the ages of 3 to 6. Yet countless studies have found that the techniques work without having to explore deep, inner anxieties, or punishing the child, or sending the kid through years of therapy.

It takes some humility, but knowing how similar we are to animals and knowing that we evolved from them, allows us to better understand how the human body and mind operate.

You see, it's good that humans are so similar to our primate cousins. We know now that just like we can train our body to do things (e.g. run a marathon, wake up at a certain hour each day), we can train our minds as well, without having to spend countless hours on a therapist's couch exploring our childhood.

Psychologist Martin Seligman created phobias in college students by giving them an electric shock whenever they saw a picture of a snake (how his research passed IRB, I don't know). It took less than 5 shocks before they developed a genuine fear of snakes, independent of a threat of an electric shock. Amazingly enough, this is the similar amount of shocks it takes for chimpanzees and orangutans! Fortunately, for us (and apes), pairing relaxation with a feared stimulus (be it snakes or a plane), produces the opposite effect.

So that is why you won't be spending too much time exploring your past when you come in for certain types of therapy. People used to assume that if you only change behaviors without exploring and "come to terms" with the past, other bad behaviors will simply crop up, or the client will still feel bad on some level. Research and lots of clinical experience actually show the opposite. Even if you just pair flying with relaxation without exploring why the phobia developed -- you can resolve the fear of flying and the person can fly comfortably, without some other phobia developing in its place.

Hypnotherapy works so well with behavior therapy because purposefully relaxing a person when they are used to feeling stress is a key element of desensitizing, hence my combination of hypnosis with virtual reality.

As I've mentioned in other sections, I'm not saying here that the past is unimportant or not worth exploring. Rather that, just like you can train your body, you can train your mind and this training really does work in a consistent manner, which takes a lot of the guesswork out of therapy.

Yet just as people got comfortable training themselves the way you'd any other animal, a new science and philosophy emerged that emphasized the thinking nature of man. Research in linguistics, neurology, and human behavior showed there was a thinking component that mediates or affects how we learn and feel. This cognitive revolution resulted in what's known today as cognitive therapy.

Adrenalin is a hormone that arouses the body. It causes an elevated heartbeat, excitement, and energy. You give an adrenalin pill to a monkey, and it goes haywire. Give the same pill to a person, and they may or may not feel that same excitement. A few years ago researchers took a bunch of volunteer college students and randomly divided them into two groups. They gave all of the participants an adrenalin pill and exposed them to an arousing event--a hyperactive student. In another variation, they were exposed to a very dramatic football game on TV.

In the first group, the researchers explained to the students that they were given a pill that would stimulate their body. In the second group, the researchers fibbed and told the students that the pill was just a vitamin pill.

What happened? The students in that second group got caught up in the excitement of the game. The first group, not so much. You see, in both groups, the adrenalin caused the students to feel aroused; however, in the first group, the students labeled the arousal as based upon the hormone. They thought "this excitement I'm feeling is just from that pill." In the second group, they had no idea the pill they just took would cause them to feel aroused. So when they did, they assumed it was because of the sports game, labeled themselves as excited, and got into the game.

Experiments have shown that emotions are the result of the cognitive labels we place on the body sensations we feel. In fact, emotions always require a cognitive label.

Here's another example. Let's say you're driving home from a visit to your grandmother. You see a car swerving in front of you and you can't quite see the driver. Chances are you'll feel care & concern. Maybe the driver is an elderly person having a problem! Maybe you should see if the person is okay. Now let's say, same car in front of you, but you just drove home after dealing with rowdy teenagers all day. The never of those kids! You see the same car, swerving. You're more likely to think "damn kids" and get angry. "Probably drunk," you'll think. You won't feel concerned but angry. Here we have the same event. But your style of thinking changes how you interpret the event and how you end up thinking.

Your reality is always biased by your thoughts, your body sensations, and what you pay attention to.

Years ago, a man named Aaron Beck discovered that people who were anxious or depressed seemed to have internal thoughts and ways of labeling things that were always overly critical. Just like you might misinterpret who's in a swerving car, people who are depressed always seem to misinterpret the world around them in a negative light. Those who feel anxious interpret neutral stimuli as threatening.

You attend a party thinking "this is going to be awful, nothing I'm going to say will be interesting or make any sense." This colors your interpretation of everything to support this thought process. Indeed, you'll actually seek out evidence that supports this way of thinking and discount any evidence to the contrary. You'll interpret a neutral event -- an awkward silence -- as supporting the idea that you're boring. Then you'll feel anxious about it. A person with a healthier self-assessment might see that awkward silence as a natural phenomenon that happens from time to time, or that perhaps the other person is a little boring as well! The end result is not getting too caught up about it.

The process of being primed to think about something occurs so instantly and automatically that most people are unaware it even happens. They just feel the resulting emotions.

Notice how in all three examples I've given, the thoughts that affect the emotions are all sub-conscious, instant, and automatic. In fact, it's because they are so automatic that we assume the thoughts and emotions are accurate and unbiased. But have no doubt: all emotions are the result of thoughts that filter what we experience. These thoughts are always biased one way or another. They happen so naturally, so automatically, that we often don't even notice when they occur.

Once Beck and others realized how universal these cognitions are, they started to identify some of the common ones that occur in people who are especially anxious or depressed, known now as cognitive biases. A classic example is known as "counting the hits, forgetting the misses." To illustrate this example in the context of cognitive therapy, here's a hypothetical conversation, between therapist (T) and client (C):

C: I just feel like I'm worthless.

T: How so?

C: Well, I haven't accomplished anything in my life! I'm a failure!

T: Didn't you just write that book and found a publisher?

C: Yes, well, I'm a writer; I'm supposed to be able to write. It's easy for me. But I'm now going through my 2nd divorce, and my kids hate me.

Here we have a client that assumes that his strengths (writing) are all innate and shouldn't "count" because it's easy for him. Yet his weaknesses (relationships) are all personal deficits that suggest he's worthless. Never mind the fact that most people would never be able to find a publisher even if they were good at writing, or that most people have some problems in their relationships (the divorce rate in L.A. County is about 70%). Or that perhaps his kids are teenagers who, by the laws of nature, have to hate their parents at some point.

In addition to counting the hits / forgetting the misses, people who are depressed tend to see themselves as all-or-nothing: either I'm a success in my career with a great family, or I'm a hopeless loser.

So as we see, these internal thoughts and internal biases, which are so universal they've been labeled and classified, end up coloring the world we live in. With people who are depressed, everything is typically labeled and filtered though the idea of being bad or worthless. With people who are anxious, everything is typically labeled and filtered though a feeling of being weak and living in a dangerous world.

When you were reading though the sample dialogue, did you notice that those statements, or perhaps the labels, hit a little too close to home? Well, with the right exercises, both behaviors and thoughts that are biased and unwanted can be changed, leading to a new set of emotions and a new sense of freedom. Keep in mind that these cognitive biases are habits, habits that can be changed.

Many people, when they first hear about disputing their thoughts and confronting their behaviors will respond, "but I already tried that!" Perhaps you tried forcing yourself to get on the plane or to not think about washing your hands. Most people, when they try and fix their thinking errors or create a behavioral habit change either go too strong too fast or fail to understand hidden aspects of their cognitions.

The reason the therapist is there is because most people don't face their fears the right way and don't realize their automatic thoughts.

Resolving a phobia is actually like learning how to run. I remember in college not being able to run for more than a minute without really losing my breath. Running for 20 minutes seemed undoable. Then I found a series of running routines: 15 steps to be performed once-every-other-day. Day one was just run one minute, walk for five for four repetitions. The next step was run 90 seconds, walk for four minutes. And so on and so forth. At the end of the first week, I was running for five minutes, to my surprise. Yet I still couldn't imagine running for ten or twenty minutes. But each week I was running more and more until by the end of the month I could run for thirty minutes.

If I attempted to just run thirty minutes right off the bat or even just run five minutes during the first day of training, it would have been too much. Likewise, behavioral interventions for phobias (as well as more generalized anxiety and depression) take a strategic path tailored to the individual that steadily resolves the phobia. It's more complicated than learning how to run but there's a similar, step-wise approach. First a person relaxes in an airport. Then on a plane that's not going anywhere. Then flying without turbulence. Then flying with turbulence. Using virtual reality and relaxation techniques (often including hypnosis) we can resolve phobias quicker than you'd imagine.

As long as a phobia can be broken down into the right steps, even very complicated phobias can be resolved in a systematic approach.

Returning to cognitive therapy, in dealing with a client, we first identify the automatic thoughts. This often takes us down a path that's very surprising for the client. As an example:

C: I'm just so afraid of gaining any more weight. I feel like such a slob!

T: I see. So let me ask you a question. If you lived on a planet where guys were only interested in girls who were overweight, girls always competed to see who could get the fattest, and where being overweight was seen as attractive and being skinny was seen as being ugly, would you want to be skinny or overweight?

C: Probably overweight.

T: So on that planet, you'd want to be overweight, right?

C: Yeah, I guess so.

T: So, it doesn't look like you have a fear of being overweight. I mean, if you'd be happy being overweight on a planet where fat people were loved and given attention. Would you be okay being fat if everyone who was fat was given love and attention?

C: yeah

T: Would you want to be skinny if everyone who was skinny was outcast? Who never found love or never had any friends?

C: No.

T: So what might you fear deep down inside? What's really scary about being overweight?

C: Not being loved.

Thus here, in this hypothetical example, the automatic thought isn't just "I'm fat" but "no one will love me if I'm fat," as well as over-generalizing: "I'm a little overweight therefore I'm fat," "no one is attractive unless they are very thin," and of course the ever-present all-or-none thinking: "either I'm perfectly thin or I'm a horrible ugly mess undeserving of love."

Typically a therapist who wants to help someone both lose weight and reduce anxiety will first target the anxiety. Anxiety about losing weight can often cause a diet plan or exercise routine to fail.

Ah, so how do we change all this? A common homework assignment I might give in this example is to send the girl to Venice Beach over the weekend. Have her count all the women who are overweight or unattractive, yet who have a guy and appear happy. Perhaps also make a special count of when the girls are more overweight than she yet are with guys she finds attractive. Invariably the list is long, much longer than she would have thought.

The next step is identifying the thoughts about being too fat as they come up. It takes a little bit of practice but pretty soon our hypothetical client here can actually hear that voice right as it says "you're so fat!"

We then take three approaches. The first approach is known as "so what if." The exercise here is to not dispute the idea of being fat but to take the air out of it. Reflect on the beach excursion. Think about other people who are fat. Now, isn't it possible they can be happy? Have a relationship? Ask yourself "am I worried about being fat, or just being alone? Wasn't I in a relationship with a guy that was really attracted to me, even though I'm the same weight now as I was back then? Isn't it possible I could be happy at the same weight?"

A universal paradox exists in regards to human growth: to best way to achieve success is to tolerate and accept failure. The best way to lose weight if you're overweight is to slow down, relax, accept that you're overweight, know it's not the end of the world, then move forward to lose the weight.

A second approach is then to dispute the idea itself of being fat. I might inquire: "isn't it true you're hard on yourself about everything? Might you also being too critical about your weight? What do your friends think- and would they lie to you? Haven't you been approached by guys before that you were interested in? Would they approach someone they weren't attracted to? If you would overlook a guy who was losing his hair, might he be more self-conscious about it than you? Could you be attracted to a guy even if he had that problem? What does that say if the roles were reversed?" Once I, the therapist, get the client to think about these questions and get her to practice asking herself these questions, they soon become internalized. Once the automatic, negative thoughts are disputed, they seem to lose their steam.

The third approach is then to lead the client to get out more and meet more people. After all, if she's afraid of being lonely, what she's looking for is to not be alone. Here the dialogue would be:

T: So a part of you felt like you were fat

C: Yes

T: and that kept you from going out as much, right?

C: Yes

T: But we see here that that was also about a fear of being alone, am I right?

C: Yes

T: ...

C: Ah. So my fear of being fat is what's keeping me alone.

T: Yes. You fear being fat because you fear being alone. Because of this fear of being fat you end up not going out, leading you to be alone, which then only reinforces the idea that you are fat and that fat people are alone.

(Insert long pause as she thinks about this)

T: Let's say I have a girl from New York and a girl from Montana. The girl from New York looks amazing in her new leather jacket but is too shy or afraid to go out much. The girl from Montana is slightly overweight but joins a weekly group hike. Which girl is likely to find love and attention?

C: The girl from Montana.

T: In fact, which girl would you rather be?

C: The Montana Girl.

T: So what I want you to do over the weekend is every time you hear the voice saying "you're fat" think to yourself "no, I'm just overly critical and even if I were fat, I could get everything I want right now if I just went out and met people." Then I want you to start to put that anxious energy into finding a hiking group or something like that.

As the client does the homework, those new thoughts become internalized and they lead to new feelings, hence the value of homework, where the majority of the positive change occurs.

Now, there's a lot more detail that we're glossing over. It would be important to find the right activity to do, gather more evidence about exaggerating/over-generalizing, and doing behavioral exercises that bring about relaxation. Perhaps the homework would be 20 minutes of daily deep-breathing exercises. And, being a hypnotist, I'd probably use hypnotherapy to both facilitate disputing these automatic thoughts and to teach the client how to relax.

By doing what's known as "autogenic" exercises, the client naturally learns to relax. That helps reduce anxiety at the source. By disputing the automatic negative thoughts, the disputing itself soon becomes automatic, and the strength of the original thoughts dissipates.

Thus, cognitive-behavioral therapy is really a series of cognitive strategies and behavioral strategies that seem to work well at making a person feel better about themselves, their future, and their world. It does take a little work and a little time to understand, practice, and refine these strategies. But most everyone who applies themselves to this end describe the process as worth it and long-lasting.

So there you have it. If you're interested in applying CBT for your own personal development, the next step is to get in touch with me to see if we'd be a good match. CBT is not for everyone but when it works, it can have profound effects.