Cognitive behavioral therapy
January 3, 2013 1:05 PM   Subscribe

Anyone that had practiced cognitive behavioral therapy?

Hello all. I recently started cognitive behavioral therapy. It was going ok for the first few days. I was recognizing my toxic thinking and then putting in a positive thought. It worked then I thought oh no what if a negative thought comes after a positive one. Then sure enough it did and every positive thought I put in place a negative follows and my anxiety gets worse. Does this hinder the whole process?
posted by Truts83 to Health & Fitness (9 answers total) 11 users marked this as a favorite
I'm going on the assumption that you're doing this with a therapist.

CBT (more than any other sort of psychotherapy) is a lot like physical therapy. Imagine you have a busted knee, and you're working with a therapist to make it better. You're not going to do great at the start. You're going to stumble and fall, a few times, and the therapist will be there to tell you what you did wrong, and why, and what to do next time so that you don't fall again. And, as time goes on and you do the work, it gets a little better and a little easier.

The only things that hinder this process is a) not genuinely working at it (doesn't sound like that is an issue with you), or b) not being in completely communication with your therapist. Unlike physical therapy, the only way a psychotherapist will know why you fell and what to do is because you told them when and where and how.
posted by griphus at 1:28 PM on January 3, 2013 [2 favorites]

Sounds normal - toxic thinking is tricky, stubborn stuff. It would be surprising if you had been able to get a handle on it in just a few days.

Some ideas that might help:
1. Step one is just recognizing when your toxic thinking is in play. Pat yourself on the back everytime you notice one, because you did notice it. Don't worry that you can't shake it yet - that takes practice (and time)
2. Do the exercise in writing. When the conversation is just in your head, the toxic thinking often ends up repeating yourself, making you challenge thoughts that you already dealt with once. If you are writing it down, the thoughts will come back, but you can just say "same as above" and not have to work so hard to rebut it.
3. Make the positive and negative sides take turns. First write down ALL the negative thoughts. Then do the counterbalancing positives. If more negative try to sneak in, tell it to wait its turn.
4. This whole thing is really an experiment in trying out new patterns in your brain. Whatever happens is what happens - that's OK. Whatever happens is just data for you and your therapist to look at with curiosity to understand better what is going on inside of you. You can't "fail" at this homework (except maybe not trying). Try not to be embarrassed to tell your therapist what was really like for you to do this homework experiment - your therapist should be supportive of your process.
5. This is a process. Be patient with yourself. It will get better but you will never be perfect. (Welcome to the human race!)
posted by metahawk at 1:29 PM on January 3, 2013 [1 favorite]

Your thought "Oh no!" is another automatic thought. It's good to be recognizing them as they happen, that's part of the process of learning how to manage them.

The therapy doesn't work by having a positive thought cancel out a negative one. It works by giving you tools to recognize when you're having those thoughts and helping you to recognize when they are not as realistic a threat as they first seem. You'll do things like think about what is the worst thing that might happen in that situation (e.g., Maybe I won't be able to stop thinking negative things and my life will be ruined), and then you'll learn to step back and evaluate how likely that is (e.g., I've had a lot of negative thoughts, but I've also had at least as many positive thoughts in my life. or I've thought negative things before and my life has never been ruined). Your therapist will help you learn to do this and it takes some practice. You say you are in the early days of practicing it, give yourself some space to learn. For now just try to remind yourself that they are just thoughts, and that you are doing good work to feel more in control.
posted by goggie at 1:31 PM on January 3, 2013 [3 favorites]

I just went through CBT a year and a half ago and I'm still benefiting from it and still learning to master it.

There's definitely some occasional backward degradation but overall progress is forward.

goggie is completely right, though. CBT trains you to recognize those self-defeating thoughts, trains you to recognize possible root causes and trains you to be able to understand whether or not the self-defeating thoughts are genuinely helpful (spoiler: they generally aren't).

Over time, you learn to discount the negative thoughts that don't do you any good and hopefully the overall sum of your experience of your internal monologue is positive, helpful and supportive of the things in life you want to be able to get done.

Over time, you learn to do internal emotional maintenance such that you are able to move through life with a generally positive tone. Over time you become the successful person you want to be because you don't spend a lot of useless time dwelling on potential negatives that you can't control.
posted by kalessin at 1:42 PM on January 3, 2013

In addition to all of the great advice above, there's also the "No!" response - an intrusive thought happens, so you think "No!" at it. Or something else you prefer that'll re-set your thoughts. I use "Monkeys!", myself.
posted by batmonkey at 1:50 PM on January 3, 2013 [1 favorite]

That thought process is sort of proof that it works. Your mood depends to a great extent on your beliefs about the world. CBT attempts to retrain your beliefs. Like anything else, it takes practice. It's a lot like practicing a sport or an instrument. Don't fret when you slip up, just be mindful of the moments and mindsets you are in when it happens, recognize them and move forward.

It's not so much about replacing a bad thought with a good one, but about reframing your reactions to stimuli, both external and internal. So the response to a negative/toxic thought is not "I suck this doesn't work I hate everyone", which of course reinforces itself, but rather "here is something that I reacted negatively to. I need to find a constructive way to deal with it. Why did it make me angry?"

Remember, you aren't trying to "fool" yourself. You aren't trying to say "I love broccoli" when you don't like it. You are replacing "Broccoli again? WTF, I hate this doesn't anyone care what I like" with "I need to eat vegetables, they are good for me and this seems like perfectly acceptable broccoli. I don't have to LOVE everything I eat. I'll get carrots tomorrow."

It is neither an instantaneous, nor an easy process. But it is very effective, and it gets easier when you get the hang of it. All you have to do at the outset is commit to the reframing process, whether or not it actually feels like it is working. It starts with "yeah, I fucking hate broccoli, but that's no reason to have a tantrum, just eat it," and then next time it turns into "it didn't kill me last time and dinner was so much more enjoyable without me complaining about the vegetables" which turns into "broccoli is not so bad." You never de-legitimized your negative reaction to broccoli, you just chose to overcome it. You've proven to yourself that you have power over your attitudes and reactions.
posted by gjc at 1:51 PM on January 3, 2013 [1 favorite]

I use a few techniques to distract myself when getting into a thought loop like you describe. The first thing I do is say to myself "it doesn't matter". This works well for me because I tend to get caught up in dwelling on the past, personalising people's behaviour and labelling them. It's all just memory, though, not something I can do anything about.

Another thing I do is make a "pshhhhh" noise, like pressurised air escaping from something. The last thing I do is a "waving away" motion with my hand. These last two give me something to focus on that isn't thought-related at all, which helps me leave the loop.

Doing these things helps me redirect myself, and helps me not get caught up in disqualifying the positive.
posted by Solomon at 2:25 PM on January 3, 2013

every positive thought I put in place a negative follows and my anxiety gets worse.

Ha, I hear you. It took several weeks of CBT before it started kicking in for me, and I went through similar panic that I was sabotaging my CBT "homework". You're still quite early on in the process. It's totally natural to angst that you're not "doing it right". If you've been had your anxiety issues for a long time, it's going to take more than a few sessions to start putting a dent in them.

But I'm kind of curious as to why you are trying to replace negative thoughts with positive ones? That's not CBT as I know it. It sounds a bit like thought-cancelling, like what goggie said. My therapist devoted at least one of our sessions to preventing me from thought-cancelling, by exposing to stimuli that would normally make me go "oh crap, bad thought, must be eliminated, time for good thought!"

It's really not the bad thoughts themselves that are the problem, as insane as that sounds. Everyone gets bad, scary, intrusive thoughts. The problem is that anxious people have more (or think they do), and that they horribly overreact to them. The CBT will get you to a place where you can say, "Oh, that bad thought again. Yes, I don't like that thought. It sucks. I'm not going to pretend it doesn't suck, but I'm also not going to let it control me."

It's very hard, but you aren't failing at this. Just keep doing the stuff your therapist is teaching you. Try not to worry that you're screwing it up (I know, I know, that's a tall order). Hang in there.
posted by Coatlicue at 5:22 PM on January 3, 2013

Congratulations on starting what can be a wonderful journey. I'll share a few learnings from my own journey with CBT, with the advice to take what is relevant and leave what is not.

The idea that cognitive behaviour therapy is similar to physical therapy is right on. I flirted with CBT for a while and had an experience similar to that which you describe. I began feeling worse not better. It felt as if I was doing something theoretically beneficial, however practically, it felt as if I was dwelling on negative aspects of life.

The professional guidance was to continue doing the practice, however to also have limits. If one's mood is very low, CBT will probably not bring it up much. As I have come to understand it, the point of CBT is not to provide immediate relief (although it can), but rather it's a process of relearning how to think and react to the world around us.

In very real terms, the beginning of the process was an experience of "things getting worse before they get better". In some ways, at the start of the practice, the CBT work ended up being an inventory of cognitive distortions. The reframing was helpful in many moments, however what was most consistent was constantly focusing on how negativity was expressing itself.

A mild "should" statement could easily – cognitively – be reframed to a more positive statement. And the resulting statement is (ideally) de-facto true. But the emotional aspect of that simple process was not quite that clean. It was as if there was an emotional residue from that quick process – "Why does 'should' keep coming up so often? What is wrong with my worldview that 'should' is such a part of it?". Then comes the ladder of thought, whereby the line of questioning ends somewhere between a family disagreement from adolescence, and an elementary school bully.

For me, that initial process was very confusing, and part of the reason that I had such a slow start with CBT. A slight boost from reframing experiences versus a consistently growing catalogue of distorted thinking. The guidance was "Do it when the result is positive. If you're not in the right place to do it, then don't do it." When one is feeling good, CBT is not exactly the first thing on the mind. It seems most helpful when one is not in the right place, but then the guidance is not to set one's self up for failure. Confusing, right?

Things get worse before they get better

The spark of innovation that moved me toward a formal practice (which has been tremendously beneficial) was the simple decision of scope. Rather than applying CBT to all of life, the full range of emotions, and any potential experience, I decided to break the process down more piecemeal approach. I started with feelings from a recent breakup, and spent three months focusing on those emotions. Whilst there was a whole host of other areas to which I could apply the process, I focused on a handful of experiences. The result was rather than exploring and cataloguing a range of different emotions/people/experiences/etc., there was a focus on a relatively tight circle of each.

The result from that was substantially better, for the catalogue of negative thoughts and resulting intrepretations was not endless, but rather bounded. I began to see where discreet events resulted in similar automatic thoughts. The process of using the manual process to reframe those thoughts began to happen automatically. Today, there are very strong memories of the moment where I realised the process was working.

I was in a nightclub called Ronnie Scotts, and having a conversation with a very attractive woman that had approached me. There was a break in the conversation, and the doubt came in. "She likes you now, but when she gets to know you, she's going to see the truth and disappear."

She had started a conversation with a friend, so there was a bit of space to explore the thought. It was a real rush when the process immediately went to work. "Fortune-telling. We have just met, and anything could happen. She might decide she likes me. She might decide she does not. I might decide that I don't like her." Then the thoughts about the previous failed relationship. "It didn't work before. In fact it really hurt. I don't want to get hurt again." And then instantly, "Discounting the positive. There were parts of the previous relationship that hurt. There were also parts of it that were amazing and I wouldn't trade for the world. There's not going to be guarantees in any relationship." And then another negative thought, and the same process. And then another, and then the same.

She turned back to speak with me, and we picked up the conversation where we left of, and spoke for hours. We drank and danced, and then dated for quite a few months after that. In the end, it wasn't the right relationship for either of us. But it didn't hurt. We had some great times, and then it was time to call it a day.

What happened that evening was that the learned behaviour (CBT) took over from the previously-automatic behaviour (negative thinking). It's as if CBT is a learned immune system. It may not be capable of stopping negative thoughts, but it's a learned process that can quickly identify them, drain them of the majority of their power, with the result that those negative thoughts stop shaping one's life and experience. That moment was exciting because it was possible to watch CBT at work.

That was four or five years ago. Since, the process has become faster and faster, until now I don't even notice when it happens. Something will happen, I'll feel a brief twinge of emotional response – almost like the pinprick of a needle – and then it's gone. There's not the indulgent follow-up of identifying negative thoughts, sitting with them, focusing on them, and operating in accordance. It's now literally a pinpoint appearance, and then they're gone.

It's interesting because it is still possible to indulge negative thinking. If a negative thought happens to appear, there's the fully capability to chase it up and sit down in the middle of it. And that's happened sometimes. When it does, there's a very weird feeling of something familiar yet also completely unpalatable. I remember that kind of thinking – and can see in memories, when it ruled my life – but it just seems like an unnecessary indulgence. It's much easier now to have positive self-esteem, and not expend huge amounts of energy on negative emotions and potentials. Bad things do happen. There are decisions, results, and consequences. Life is still life, but all of that comes in it's own turn. I've found there's not any result from negative thinking other than putting me in a dour mood.

I continued deploying the CBT toolset discreetly within my life. The next area of investigation was related to work and career. Again, a specific scope of people, experiences, and emotions. The outcome was similar as the first line of inquiry. I began to see where rather diverse sources of stimulus were resulting in a common set of negative thoughts. I diligently did the homework to target replacing that specific set of negative thoughts.

The timeframe involved here is about three years, from six months flirting, to six months giving up, to two years of intensive practice. In the latter two years, I did a CBT journal (based on Feeling Good by David Burns) at least a few times a week. On some occasions, I did two journals a day.

In retrospect, what I was doing was inoculating thinking against automatic negative thoughts. It's literally retraining the brain – dendrites, synapses, and neurotransmitters – as well as the mind – perception, memory, and decision-making – to respond differently to outside events.

The first year was quite tough. I often didn't feel like myself. The behaviours resulting from negative thinking were often downside-minimising, or staying in the comfort zone. It involved saying no to things that I really wanted to do but hadn't done before. It involved maintaining relationships that were actually quite negative. It involved often being in a familiar place of chronic discomfort. Doing the CBT place moved me to an unfamiliar place of acute discomfort, followed by bliss, euphoria, and a feeling of really being alive.

Rather than downside-minimising, I became pragmatically optimistic. It may not sound like much said in that way, but it felt as if I had a whole new life. I had been living for so long with negative thinking, that I thought the world really was like that. Filled with threats, and a healthy dose of paranoia and low expectations being par for the course. It's not, and it isn't.

To this day, I do maintenance journals as a source of self-monitoring. There's always going to be negative thoughts – that is very important to understand. The goal of this process is not perfection. It's easy to shoot for perfection, and give up when the results are slow and hard-earned. The point is that not all negative thoughts are valid – in fact, I've found the majority of them are not. There are negative thoughts that are very important to listen to. Thankfully, they are often accompanied by a significant emotional response as well. Basically, negative thoughts that need attention are not as much negative thoughts, as overall wholly-negative experiences.

In terms of where you are, I would say keep at it. Go at your own pace. Find a practice that works for you. Don't expect to see immediate progress, but rather consistent progress. The day you find yourself thinking something negative, and immediately replace it with identification of a cognitive distortion, you are well on your way. CBT is doing its work in interrupting the negative thought process. You may still go on the negative thought journey after that, but the point is you are wiring yourself to identify those thoughts. That's the first (and arguably the hardest) step. You can't remove an infestation that you can't find. And finding those negative thoughts – automatically identifying them – is the (very powerful) first step.

Good luck and take care.
posted by nickrussell at 1:04 AM on January 4, 2013 [4 favorites]

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