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 my disclaimer regarding
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 as classical and operantconditioning).
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
as assertive communication skills to deal with social situations andrelaxation
skills to 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 as Alfred Adler, and partly in the Stoic
philosophers of ancient Greece who were introduced to psychology by Albert
Ellis. Ellis may be considered the first psychologist that produced a fullyformed version of cognitive therapy beginning in the 1950s (now
calledRational Emotive Behavioral Therapy). Aaron Beck also 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 the behaviorist tradition of psychology,
particularly influenced by the research of Ivan Pavlov and John B.
Watson early in the 20th century and B. F. Skinner in the mid-20th century. An
important early behavioral therapist was Joseph Wolpe. An important theorist

and researcher who helped to bridge the gap between the cognitive and the
behavioral is Albert 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 CBT by 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
of
Psychology, 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 of Research Supported Psychological
Treatments, many of which are based on CBT.

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CBT 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 my Introduction to CBT and my disclaimer regarding 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 patterns2 of 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 by Aaron
Becks version of cognitive therapy, Albert Ellis produced a similar list that
highlights what he called irrational 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 the Cognitive
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). Questions3 that may help you to identify thoughts are:
1.
2.
3.

What is going through my mind as I am feeling this emotion?

What am I telling myself about this situation?
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.
2.
3.
4.
5.
6.

If this thought is true, what does this say about me as a person?

What does it say about my life, and my future?
What is the worst thing that could happen if it is true?
What does this mean about how other people think about me?
What does this mean about how I think of other people?
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 questions3 can help you evaluate the accuracy of a thought:
1.
2.

What is the evidence that supports or contradicts this thought?

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 the usefulness of 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 as behavioral activation (for depression) and exposure(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, by Judith 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

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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 my Introduction to CBT and my disclaimer regarding
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 the Centre 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 my disclaimers regarding the information provided on this website,
the links to external information, and my lists of possible referrals.
-Last updated 02.05.11

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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
my Introduction to CBT and my disclaimer regarding 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, including Generalized Anxiety Disorder,Obsessive Compulsive
Disorder, Panic Disorder, Posttraumatic Stress Disorder, Social Anxiety

Disorder, and Specific 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
(see cognitive 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
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Exposure therapy