What is Cognitive Behavioral Therapy?

Cognitive behavior therapy (CBT) is often the first type of treatment recommended for adults and teens with bulimia nervosa and binge eating disorder, but what is it? And does it really work?

CBT is a very well-studied psychotherapy. Originally pioneered by Aaron Beck at the University of Pennsylvania in the 1970s, CBT has been tested for a wide range of mental health conditions. Among them: depression and other mood disorders, anxiety disorders, post-traumatic stress disorder, insomnia, and eating disorders. The base of evidence suggesting that CBT is helpful is, at this point, robust. Like the use of antibiotics for an ear infection, there is no question that it can be useful.

The main tenet of CBT is that our thoughts, feelings, and behavior are all closely interconnected, including in ways that sometimes operate just below the surface of our conscious awareness.

As an example, imagine you’re walking down the hall. You see a good friend. You say hello, and your friend does not respond. You think: “Oh no, she’s mad at me.” You feel anxious and then think: “I’m being rejected.” You get more worried. Because you feel worried, you do not text your friend later in the day. And you cancel plans to hang out with a different friend that evening.

Now imagine the same scenario, but when your friend does not respond to you in the hallway, you instead think: “Ah, she must not have seen me.” You say hi again in a louder voice, and she responds as normal. You feel pretty neutral, and your actions later that day are unaffected.

In these scenarios, the situation is the same: your friend didn’t say hello when you initiated contact. But just thinking about it differently has an important impact on your response, how you feel, and what happens next.

How does CBT work?

In CBT, we directly work on thoughts (The “C,” for cognitions) and actions (The “B,” for behavior). There is an assumption that addressing thoughts and/or actions will influence emotions. The theory is that simply by understanding the links between these three elements of our moment-to-moment experience, we can develop behavioral experiments or learn skills to shift our mindset and address cycles that are causing us problems. Here is a bit more about how:

The B

In CBT, behavior (behavioral experiments, specifically) can be used to challenge thoughts. For instance, imagine you believe that if your homework is not perfect, then you’ll fail. You spend extra time re-doing it until it is perfect. In CBT, we design a “behavioral experiment” to test if this is true: turn in your intentionally imperfect homework to test the belief that imperfection will lead to failure. This helps to collect evidence and use this information to assess (or adjust) beliefs.

The C

There is a range of techniques in CBT for challenging problematic thoughts, including behavioral experiments and more direct strategies. In CBT, we learn to identify common mental shortcuts that tend to steer us wrong some of the time. Consider, for example, mind reading (i.e., “I can tell she thinks I’m ugly.”) and should statements (i.e., “I should be thinner.”). Labeling a thought is the first step in stepping back from it and evaluating its “truthfulness.”

CBT sessions are structured and the therapist and patient work together to set a plan for each meeting that aligns with treatment goals. A key component is practicing skills between sessions. That’s right: homework. Homework might involve trying out new ways of doing things and evaluating the outcome, keeping written or electronic real-time records of eating behavior, mood, or other symptoms, or practicing skills when the occasion calls for it.

Feeling skeptical?

I was too! I was skeptical of CBT when first introduced to it in graduate school. Over a decade into clinical practice, I have been converted from skeptic to advocate. My past hesitations about CBT were similar to what some patients voice to me: “If it was easy or possible to change my thinking, I already would have done it!” or “Thinking positive doesn’t work…”

Remember, CBT is not about using affirmations – going all positive thinking all the time – it’s about developing a set of skills for noticing and intervening when you might be biased, trying on new choices and mindsets, collecting data, and analyzing the information you gain from lived experience.

Treatment as part of our clinical research program.

At NYSPI, we conduct comprehensive eating disorder evaluations for teens and adults interested in participating in clinical research. Currently, one of our teen studies is recruiting girls who experience recurrent binge eating for a study that uses EEG and smartphones. Participants in this study may receive CBT – or other kinds of treatment – at no cost if eligible and interested. The specific type of CBT we offer is especially for individuals with eating disorders. For more on what it means to receive clinical care in a research setting, read this related post.

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