Cognitive-Behavioral Therapy is used all around the world to help people with many different problems like anxiety, depression, anger, relationship problems, substance use, accomplishing goals, and motivation.
We created a video to help people understand fundamental CBT tools and ideas to improve their lives.
The Here and Now Habit by Hugh G. Byrne is a short, 182 page, book on how we can use mindfulness to help change habits. If you’re unfamiliar with mindfulness, the basics are thoroughly covered in a reasonably common-sense kind of language frequently lacking in mindfulness books.
Habits
Our habits are routines we execute with minimal conscious decision-making. Most of the time, this is great news because we can save time and energy by not having to spend too much time thinking about what we do throughout our days. Most of our habits are probably harmless and/or even helpful. For example, I have a habit of showering and brushing my teeth in the morning. However, sometimes our habits are less than helpful for a variety of reasons.
Most of our habits can seem quite “mindless”, because they are automatic. We might be unaware of changes in our minds and bodies that prepare us for engaging with our habits. When we start cooking dinner, we might think, “a glass of wine would help me relax”, and then we might feel dryness in our mouth signifying thrust. More generally, we might just get an overall sense of discomfort (cravings) that we believe will be relieved if we have a glass of wine. Then if we execute the habit (have the glass of wine, eat a bowl of chips, do some online shopping, etc.) we tend to experience relief. This pattern of discomfort – habit – relief is reinforced over time and this is how a habit is formed.
Mindfulness
Depending on who you ask, “mindfulness” can mean several different things. I like Jon Kabat-Zinn’s descriptions of mindful as present moment awareness without judgment and with acceptance. One of the basic premises of mindfulness is that as we develop our skills for paying attention to the present moment, our tolerance for uncomfortable thoughts, emotions, and physical sensations increases. I’m definitely not a mindfulness expert, but from what I have learned over the last 10 years, it seems this increase in tolerance is the result of two processes. First, as we get better at being mindful, we get more skilled at regulating our emotional responses and relaxing the body. Second, as we practice watching our bodily sensations, with curiosity instead of judgment, we learn that our sensations, emotions, and thoughts are temporary and we do not need to fear them. If we are feeling sad, we can observe where we feel sad in our bodies and let go our sad thoughts/sensations. If we practice this enough, we learn our feelings of sadness are temporary, especially if we are skilled at practicing relaxation skills like mindful breathing techniques (if you’re interested in learning more about mindfulness, I recommend the book Aware by Dan Siegel).
How we can use mindfulness to change habits
Put simply, if we accept that our habits are a way of giving use relief from discomfort, Byrne suggests we can use mindfulness to provide ourselves with this relief instead of the unhelpful habit. As an example, lets say I have a habit of eating fast food instead of the healthier lunch I take to work (a completely factitious example I assure you). Before my break, I might have thoughts about going to the local pizza place and I could start having cravings. In that moment, I could go through with my unhelpful habit to satisfy that craving, or instead I could take a moment, and practice some mindful breathing and watch the cravings I am having in my body. Instead of thinking “What’s wrong with me?! Why is this so hard?! I should have never have gotten into this habit, I’m such a loser” (because all of these would be judgments), I simply observe where I feel the cravings in my body. Cravings are like waves, they can seem overwhelming and smash into you, but in time, they always recede. So, I observe the wave of cravings with my mind and in time I feel better. When I feel better, I am no longer on autopilot but I can make a choice that is consistent with my goals of eating healthier. The process of discomfort – mindfulness – relief becomes the new habit over time.
Conclusion
The Here and Now Habit by Hugh G. Byrne is a thought provoking book that provides some interesting information about habits and mindfulness in understandable language. At the moment, I do not have any habits that I am trying to change, but when I aspire to making changes in the future, I will be happy to review this book and try its recommendations.
This is a great podcast about Cognitive Behavioral Therapy done by Dr. David Burns, the author of the great self-help book “Feeling Good.”
I frequently listen to this podcast, it’s great for both clients and therapists. Here are some topics discussed:
Self-defeating beliefs
Overcoming perfectionism
The defiant child
Anxiety and Depression
Negative thoughts
Click here for a link to their webpage.
Lots of people struggle with identifying their thinking. Some insist that they are “just anxious” and they have no worries creating this anxiety. While it may be the case that some health conditions can produce an anxiety like response, CBT suggests that the vast majority of the time there are thoughts or beliefs creating our emotions and there are some tools we can use to help identify them.
This is a fundamental technique in CBT. Our feelings are excellent clues into what we are thinking. Also, since we frequently misuse the word “feel” in English, sometimes our “feelings” are actually thoughts in disguise. For example, woman struggling with guilt about parenting insisted she couldn’t identify her thoughts when she felt guilty. When describing the situation in therapy she claimed “I just feel like a bad Mom.” This was immensely helpful because she had been confusing her feelings with her thoughts. She felt guilty and she thought “I’m a bad mom.”
Even when we are not confusing thoughts and feelings, our emotions give us hints about our thinking. As described above, when we are anxious we are usually worried about something, when we are depressed we are usually thinking negative thoughts about ourselves, the world, or our futures, and when we are angry we are usually thinking about what “should” happen or how someone “should” behave. Sadness tends to be about loss, guilt about judgments about our own behavior, and embarrassment tends to be created by assumptions about how others might judge us.
You can improve your skills of identifying your thoughts by checking-in with yourself next time you have a feeling. So next time you feel anxious ask yourself “what am I worrying about?”
The first technique is very simple, but usually can be effective for most people. This technique involves carrying a small notebook, a piece of paper, or a cue card with you (and a pen) and writing down any automatic thoughts you have when you feel anxious, depressed, angry, etc. You can also use worksheets to help with this process. Here are some hints for writing down automatic thoughts:
Although this one can seem silly, it can be one of the most effective skills for identifying thinking. Simple think of a time when you were feeling depressed, anxious, angry, etc. Then draw a stick person in that situation. Here’s an example of a stick-person getting anxious when they saw a snake when he was on a hike with his stick-girlfriend:
Then simply guess or imagine what the stick-person might have been telling himself in this situation to create his anxiety.
Usually, what we imagine the stick person might have been thinking is precisely what we were telling ourselves in this situation.
Other techniques to become more aware of our thinking include meditation and free association. These techniques encourage us to be mindful or our thoughts in the present moment.
Once we can identify our thoughts, we can then use cognitive-restructuring techniques to change the way we feel and/or behave.
Daniel Kahneman won the Nobel Prize in 2002 for the work he, and fellow psychologist Amos Tversky, began in 1974 when they and published their article “Judgment under Uncertainty: Heuristics and Biases” in the esteemed academic journal Science (Vol 185. Pp. 1124-1131). Tversky and Kahneman sought to understand how humans made decisions in uncertain situations. This work suggests people use a series of mental processes to make decisions and the underlying machinery of these mental processes tends to make predictable errors. Their findings have profound implications for our understanding of mental health.
Anxiety is the product of perceiving a threat to something we value. In the simplest terms, when we believe there is a bear (a threat) in the bush near us (something we value) our body gets ready to run/fight/or freeze (anxiety). This simple formula can take far more advanced forms because we can value other things besides our own physical health and threats can take many forms beside that of a bear. While threats and things we value can take many forms, our bodies only have a small number of responses. These responses are run, fight, or freeze and we interpret our bodies getting ready to do these things as anxiety. For example, public speaking is perceived to be a threat to our goal of being perceived as competent and confident, taking a test poses a threat to our hopes of completing a class with a particular grade, and running out of gas threatens our goal of getting where we want on time. Our bodies will get ready to deal with all of these threats in the same ways – by making us anxious.
If we accept this formula as an explanation for why we get anxious, this leads to another reasonable question: How do we decide how much of a threat something is? Tversky and Kahneman provide us with an answer but first let’s consider some other questions:
To answer these questions our minds could use a number of different strategies. Our minds could list every known English word that is 3 or more letters, then compare how many begin with K and how many have K as the third letter. Even if we used this exhaustive and thorough strategy, our answers would be imperfect because we do not know every English word so we would be guessing based on the words we do know. As for the questions about heart attacks and honesty, we would never truly know the exact values because we are not omniscient and honesty is not something you can quantifiably measure. However, most people do not find it difficult to come up with answers to all of these questions. In fact, people tend to come up with answers extremely quickly.
When we are asked questions like these, our minds take the question we have been asked then quickly replace this very difficult question with a simpler question like “How easily can I remember or imagine something like this?”
If you are like most people, when asked the question about the letter K, you tried to think of words that begin with the letter K or had K as the third letter. If you could easily recall words beginning with K, but had greater difficulty thinking of words with K as the third letter, you concluded there must be more words beginning with K. Words with K tend to be easier to recall and most people assume there are more words beginning with K, even though there are more words with K as the third letter in English. Instead of being able to provide the true likelihood of heart attacks, our mind replaces this question with something like “How easily can you remember or imagine a middle aged man having a heart attack?” Then finally, you likely replaced the question about honesty with “How easily can I remember situations in which I was honest and dishonest?” It is not about how many memories we have being honest or dishonest, we form our judgments on the availability of those memories. Memories we can easily recall are said to be more available to our conscious minds than memories that are difficult to recall.
This mental “trick” is called the “availability heuristic.” As Tversky and Kahneman explain in their 1974 article, “There are situations in which people assess the frequency of a class or the probability of an event by the ease with which instances or occurrences can be brought to mind” (p. 1127). In other words, we believe something to be more likely if memories or fantasies of similar situations are “available” to our conscious mind. Most of the time the availability heuristic serves us pretty well. If something frequently happens in our life (the sun comes up every morning), one can assume it is likely for it to happen again without many costs being associated with this prediction. This allows us to avoid living in a constant state of uncertainty, predict what is likely to happen in the future, and plan accordingly. Unfortunately, the availability heuristic can be biased and sometimes this can have serious adverse consequences.
The availability heuristic is disproportionately influenced by recent and emotionally salient situations. Following a traumatic experience, people are far more likely to overestimate the probability of a similar traumatic event happening which artificially inflates our perceptions of how threatening a situation is, which in-turn unnecessarily increases anxiety and distress. Following a car accident, you will likely overestimate the likelihood of being in another car accident, which increases anxiety while driving. Following 9/11, many of us felt a new anxiety we did not previously experience while getting on air planes, not because flying was anymore dangerous (flying had probably never been safer than after 9/11) but because memories and fantasies of planes being high jacked were far more available.
We determine which situations are threatening not by assessing the true threat level, but by assessing how easily we can remember or imagine similar situations ending-up poorly. Panic disorder can manifest in a number of ways, everyone is different, but people with panic disorder tend to worry that bodily sensations (heart arrhythmias, increased heart rates, accelerated breathing, dizziness, sweating, etc.) are evidence of a serious catastrophe (heart attack, stoke, going insane, etc.) which escalates anxiety resulting in panic attacks. Once we’ve had a single panic attack, the memory of this experience can be particularly available because panic attacks are so emotionally distressing. If we have had a panic attack in a store, we might later wonder about the possibility of having a panic attack in another store like Walmart. This question about the probability of having a panic attack in that particular Walmart at that particular time is replaced with “How easily can I imagine having a heart attack in Walmart?” If the answer is “very easily” then, we will assume the likelihood of having a panic attack in Walmart is high and we will likely avoid Walmart to avoid having another panic attack.
In obsessive-compulsive disorder (speaking of true OCD not the “OCD” people claim to have when they have strong preferences for cleanliness or organization), people can grossly overestimate the likelihood of someone breaking into their home and murdering their family because this specific fantasy can be incredibly distressing. When a fantasy is emotionally distressing, it is more available to consciousness, and this availability inflates perceptions of likelihood. Put simply, because the obsession is so upsetting, people will think it is likely, and they will act compulsively to reduce the probability of the feared event occurring.
In addition to anxiety disorders, the availability heuristic also plays a role in the development and maintenance of other mental health challenges. People with eating disorders often worry that people will judge them negatively if they were “fat.” They sometimes have vivid fantasies of being publically ridiculed or rejected for having what most people would consider to be an average or even below average weight. The maintenance of an eating disorder is riddled with availability heuristic errors. Often people will be able to easily imagine people judging them for being “fat” because they themselves frequently judge other people as fat and they take this as evidence suggesting other people have similar thoughts. The memory of their own judgments will be available because they are so frequent and this will inflate their perception about the likelihood of other people being judgmental like themselves. There are often historical traumas in childhood in which the person with the eating disorder was indeed bullied, mocked, and/or criticized, sometimes by close loved ones. While memories of this abuse are no longer recent, they may be incredibly available because of their emotional salience. They may also judge themselves as inadequate because they can easily recall examples of “beautiful” celebrities which inflates their perception of the regularity of these “beautiful” people.
When we are depressed, we will often have negative automatic thoughts about ourselves like “I’m a failure” or “I’m a loser.” Our minds will form these judgments by seeing which memories are most available, so if we can easily recall examples of “failures” or “losing”, we will be more likely to make judgments consistent with these memories. Since we tend to feel negative emotions more intensely than positive emotions, memories involving failure and loss may be easier to recall, and so these memories bias the availability heuristic and negatively distort our judgments.
The availability heuristic seems to be at the heart of many mental health challenges and this has some interesting implications for the treatment of mental illness. The availability heuristic is biased by recent and emotionally evoking memories and being aware of these biases allows us to think critically about the assumptions we make. In his 2011 book “Thinking, Fast and Slow” Daniel Kahneman explains “Resisting this large collection of potential availability biases is possible, but tiresome. You must make the effort to reconsider your impressions and intuitions by asking such questions as, ‘Is our belief that thefts by teenagers are a major problem due to a few recent instances in our neighborhood?’ or ‘could it be that I feel no need to get a flu shot because none of my acquaintances got the flu last year?’ Maintaining one’s vigilance against biases is a chore – but the change to avoid a costly mistake is sometimes worth the effort” (p. 131). This method of monitoring and thinking critically about our assumptions is identical to the cognitive restructuring interventions used in Cognitive-Behavioral Therapy.
In addition to cognitive restructuring, exposure based therapies may also be used to combat the biases of the availability heuristic. It’s no surprise that people tend to avoid anxiety provoking situations. As Dr. David Burns explains in his book When Panic Attacks:
Most people who are anxious avoid the things they fear, so they never experience enlightenment or relief. If you’re afraid of heights, you’ll avoid high places because they make you feel dizzy and anxious. If you’re shy, you’ll avoid people, because you feel so insecure and inadequate. The avoidance fuels your fears, and your anxiety mushrooms. If you want to be cured, you’ll have to face the thing you fear the most. There are no exceptions to this rule. (Pp. 252-253)
Imagine a person who has a panic attack on an elevator. Following this experience, when the person’s mind attempts to calculate how dangerous a particular elevator is, it will not be calculating the true risk of taking the elevator because this is truly unknowable for every elevator in the world at any given time. It’s not like their mind will know there is a 1.2496% chance something goes wrong if they get in that elevator right now and remain in it for 28 seconds. Instead, they will replace the question, “How dangerous is this elevator?” with “how easily can I recall having an uncomfortable emotional experience in situations similar to what I imagine it is like to be in that elevator?” The memory of their last panic attack in the elevator will be very available because it is so emotionally evoking, even if it is not recent, and so the person will conclude getting on the elevator will be very dangerous. However, if the person decides to go into the elevator, even though they feel anxious, there is very little chance anything will go wrong. They will likely feel anxious and perhaps even have another panic attack, but after a few minutes this anxiety will dissipate. If they stay until their anxiety is gone, they may even feel pride and excitement about their achievement. Let’s say they repeat this exposure exercise 5 or even 10 times. The next time they wonder about how dangerous it is to get on an elevator, the memories of taking the elevator with nothing bad happening will be far more available and they will conclude the elevator is likely safe.
I recommend combining both of these cognitive and behavioral (exposure) approaches. Be mindful of how and why your mind is making the predictions and judgments it is making, but also go and have positive experiences to replace the negative memories creating these predictions and judgments. As you change your assumptions, predictions, and judgments through cognitive restructuring and exposure, you’ll experience serious emotional changes.
To be thorough, lets consider an example in which a person is depressed. As mentioned above, people who are depressed frequently experience negative judgments and predictions. We can fight depression by identifying and thinking critically about these judgments and predictions. So when we tell ourselves things like “I really can’t do anything right” we notice these thoughts and write them down, or record them in some way. Writing down our thoughts is a great way of distancing ourselves from what we are thinking. Then we think critically about these thoughts by simply asking some questions like “What memories is my mind accessing when I think I can’t do anything right? Are there other examples of me doing things reasonably well that my availability heuristic is ignoring? I put my pants on today correctly, is that not an example of doing “anything” right? So if I have done somethings right, like putting on pants, what do I really mean when I think I can’t do anything right? Do I mean that I have some regrets and if so, how do I know I have more regrets than other people? Even I have done more regretful things, what can I do about it? What is the value to ruminating on these regrets?” So this is one example of a cognitive restructuring technique called Socratic Questioning.
To combine our cognitive restructuring with a behavioral technique to combat the biases of the availability heuristic, we might create a list of things we could do to have the experience of doing something right. To make this list we might ask, what are some things you would be proud to do? Things like hike a mountain, read a book, volunteer, get a job, take a class, or clean up a local park. Then the depressed person would go and do these things, even if they don’t feel motivated to do so (action comes first, motivation comes later). The person would take photos of how they did and this would serve as evidence to dispute future thoughts about not doing anything right. Combining both these cognitive and behavioral approaches will help the person to become less depressed over time by combating the availability heuristic’s biases for emotionally evoking and recent memories.
To summarize, the availability heuristic is a mental process we use to make predictions and judgments. While it frequently helps us make complex decisions effectively, it is also biased to overemphasize recent and emotionally salient memories and fantasies. Unfortunately, these biases can create and maintain challenges like anxiety and depression. Cognitive restructuring and exposure techniques can help us challenge the underlying thinking which contributes to these problems.
Postscript
I’ve been studying the work of Tversky and Kahneman for several months now, beginning with the Michael Lewis book “The Undoing Project” which tells the amazing story of how they changed the world of psychology, economics, health care, finance, marketing, and so many more fields. Judgment under Uncertainty: Heuristics and Biases is a brilliant 7-page article that can be found for free – click here. Daniel Kahneman’s book Thinking, Fast and Slow is a fantastic insight into our minds and how they work.
There are many reasons people resist making positive changes in their lives. As a therapist, the number of reasons I’ve heard for not making a change is truly astounding. When I talk about this with people, they explain it’s obvious – people don’t make changes because they “fear change.” I’ve always found this explanation to be unsatisfying. It sounds like another example of people wanting a simple explanation for something complicated. Why do people fear change? What specifically about change do people fear? I tried to answer these questions by reading Robert Leahy’s “Overcoming Resistance in Cognitive Therapy.” From this book, others like it, and my own experiences, I have learned resistance does not interfere with therapy, overcoming resistance is the therapy. Most people have an idea of how they could make a positive change in their lives, but they typically resist making these changes. One of the most interesting chapters in Leahy’s book describes the “Investment Model of Resistance” and how it applies to people with depression.
When people are depressed they are less likely to engage with activities which would likely reduce their depression. Instead of problem solving, exercising, socializing, working, sleeping 8 hours, and eating a healthy diet, people with depression are more likely to isolate, withdraw, conserve energy, and avoid. This is referred to as the “depressive paradox.” When people are depressed, one would expect them to be more motivated to pursue pleasure and meaningful engagement. Like how a starving person becomes intensely motivated to acquire food. From this perspective, avoiding potentially rewarding and enjoyable experiences seems to make no logical sense. As opposed to accepting a person with depression is simply illogical and self-destructive, Leahy’s Investment Model of Resistance suggests people with depression are primarily motivated to avoid losses, failures, and rejections, as opposed to being motivated by the possibility of acquiring the potential benefits of making a change. Like how a person who is intensely afraid of losing money will turn down a great investment opportunity because they cannot tolerate even a minimal amount of risk. Leahy suggests there is an underlying logic to the decision making of a depressed person, but this logic is based on distorted assumptions and beliefs.
Aaron Beck is one of the founding fathers of Cognitive Behavioral Therapy. Beck’s Cognitive Model of Depression is an immensely valuable contribution to our understanding of depression. Beck suggests negative life experiences result in the formulation of dysfunctional assumptions about the self, the world, and the future. For example, people with abusive or neglectful parents may develop 
the assumptions that they are truly inadequate losers, others are a source of rejection and criticism, and they will inevitably fail and end up in unsatisfying relationships or be abandoned. Our dysfunctional assumptions become triggered by critical incidents (losses, failures, criticism, rejection, etc.) and this results in negative automatic thoughts (“I’m a loser”, “why can’t I do anything right”, “I’m going to end up alone”, “I have no real friends”, etc.). These negative automatic thoughts lead to extreme emotional responses (sadness, hurt, guilt, anxiety, etc.) which then leads to exaggerated behavioral responses (withdrawing, isolating, defensiveness, people-pleasing, conserving energy, etc.). We describe this combination of unhelpful and distressing thoughts, feelings, and behaviors as depression.
I combined Leahy’s Investment Model of Resistance with Beck’s Cognitive Model of Depression in an attempt to better understand how depression can originate and be maintained. Once we formulate dysfunctional assumptions from negative life experiences we may try to avoid critical incidents which may confirm their dysfunctional assumptions. For example, if we believe that we are unattractive we avoid asking potential mates out on dates, because the rejection could trigger too much pain and hurt. Sometimes we can be moderately successful at avoiding critical incidents and we can be “fine” for a long time. Unfortunately, loss, failure, criticism, and rejection are unavoidable parts of the human experience regardless of how much we attempt to avoid or overcompensate. When we inevitably have one of these experiences, this activates our dysfunctional assumptions. We assume our skills are inadequate, we cannot cope with further losses/failures, and our resources are minimal (viewing energy and effort as finite and minimal). We fail to recall previous successes and assume/believe our lives have been an unending and unwavering pattern of misery which influences our predictions about the effectiveness of making positive changes. We also view the costs of even minor failures/losses as catastrophic and assume we will continue to fail into the future. As Leahy explains “To the depressive, losses are not simple inconveniences. Rather, they are interpreted as salient, personally relevant, morally significant, and predictive of further losses in other domains. Ironically, because losses are so overvalued, the depressive will avoid loss at all costs.”
The Investment Model of Resistance suggests when our dysfunctional assumptions are activated, we fear further failure and loss. This fear motivates us to avoid situations that could potentially give us some benefit (go for a run, call a friend, find a new job, enhance our education, prepare healthy meals, problem solve, etc.) because each of these situations also pose the possibility of failure, loss, and rejection. In some cases the costs of making a particular change are obvious (like financial costs), in other situations the costs are more discrete. An example of a discrete cost might be the loss of energy associated with making a particular change. Some ways we may avoid making changes include requiring more “motivation” prior to making a change, trying to not think about our problems (excessive distraction and sleeping for example), demanding a 100% guarantee we will succeed before trying, and insisting someone else solve our problems for us.
If we do muster the energy and motivation to try something, we often quit at the first sign of failure or loss. Many people that are depressed try problem solving, exercising, socializing, practicing gratitude, etc. Perhaps we tried once, for a week, a month, or maybe even 6 months but our depression undermines our attempts to make progress in a number of ways.
When we are depressed we have a high threshold for perceiving gains and a low threshold for perceiving costs. When we try something and don’t get a full remission of depressive symptoms, we conclude it didn’t work at all and if something even remotely undesirable happens, we believe it to be a catastrophe. Even minor losses/failures are turned into catastrophes by the person’s own excessive and unrealistic self-blame. This is sometimes “all or nothing thinking” or “catastrophizing” and is an example of cognitively distorted thinking. Take for example, the person who musters their courage to disagree with their partner for the first time in their relationship. Naturally, when we are setting boundaries we may be changing established relationship dynamics that may be working for the other people in our relationships. So when we are assertive and our partner responds with anger and frustration because we are trying to change the relationship dynamics that may be working just fine for them, we may have the negative automatic thought “I tried and it was a disaster.” In this example, we are failing to identify our gains – practicing our assertiveness skills and communicating our boundaries. It’s similar to the person who has never played basketball concluding they will never be able to play because they missed their first three point shot. Our high threshold for perceiving gains is also influenced by our causal explanations for our successes and failures. If we do something well, we blame transient and external factors like luck or the task being so easy anyone could do it. On the other hand, when we do something poorly we blame stable and internal factors like our own inadequacy. This reaffirms our distorted beliefs that we are inadequate, all we have done is fail, and all we will ever do will fail.
When we are trying to make positive changes in our lives costs often precede benefits. So if we quit after paying the cost of making a change but before attaining the benefits, we can conclude further effort would be futile. Furthermore, the benefits may be subtle and go undetected. For example, suppose you added daily exercise to your routine. Exercising costs us time, energy, and comfort before we get the eventual, but often subtle, benefits of exercise. In this situation, it may be easy to have the negative automatic thought “exercise doesn’t help at all, I exercise daily and still feel depressed.” However, our daily exercising may be providing us with the undetected benefits of protecting us from further depression, diabetes, hypertension, high cholesterol, chronic pain, etc. While it may be true that we are still depressed despite exercising, we cannot know how much worse we would be without exercising. Also, if exercising does not work (provide a complete remission of depressive symptoms) we also lose it as a possible solution to our problems. As the list of possible things we can do to get out of our depression gets shorter there is additional evidence for our dysfunctional assumptions that we are inadequate and will never get better.
Our outright avoidance of making potentially beneficial changes and our trying a solution but quitting before attaining benefits, not only undermines our problem solving but it actually creates new problems. For example, if we avoid exercising, we not only have to deal with our depression persisting but we may also develop serious health complications in the future. If we try to set boundaries with a behaviorally challenging teenaged child but we quit because it didn’t get the results we wanted quick enough, the child’s behavioral problems could continue to escalate and create new problems. Similar to the patterns above, the development of new problems then reinforces the assumptions about our inadequacy and our inevitable failure.
Leahy also identifies another aspect depression which may contribute to resistance of making positive changes. Leahy suggests people struggling with depression develop assumptions about being “sadder but wiser” which may reinforce their dysfunctional assumptions. From their experiences of perceiving constant failures and losses, they come to believe they have an accurate view of the world as negative, hostile, and filled with suffering. They may even derive some satisfaction and a sense of superiority from arguing with others about how their view of the world is accurate, which will reinforce these assumptions. Those struggling with depression may even use their own self-sabotaged attempts to make progress as evidence in support of their arguments. This is the “I’m going to fail, I’ll try but quit when I don’t get the results I want, oh look I failed, I was right all along” rationale. As explained by Leahy “By proving that he is correct about his negativity and that the therapist is Pollyannaish in his optimism, the depressive believes that he has achieved some “victory” – he has proven the therapist wrong. Even though this may add to his sense of hopelessness, he at least feels some momentary superiority to the ‘naïve therapist.’” Granted there is no shortage of horror, despair, and suffering in the world but to focus exclusively upon these aspects of the human experience provides a biased and cognitively distorted perspective. Although you may briefly feel satisfied and superior by arguing you are “sadder but wiser”, in my opinion the costs of remaining stuck greatly outweigh these potential benefits. I was unsure about how to add the development and maintenance of this “sadder but wiser” philosophy to my model but I thought it was an interesting idea and worth mentioning in this article.
My combining The Cognitive Model of Depression and The Investment Model of Resistance is my attempt to explain how depression is developed and maintained. As opposed to being “afraid of change” or “irrational”, my model suggests people with depression are primarily motivated to resist making positive changes in their lives because of fears of further failure and loss associated with dysfunctional assumptions. I’ve kept Beck’s emphasis on the development of dysfunctional assumptions by negative life events and the activation of these assumptions by critical incidents. I’ve attempted to expand upon the “negative automatic thoughts” portion of Beck’s model by including cognitive processes from Leahy’s Investment Model of Resistance. In my combined model, negative automatic thoughts are expanded to include fears of further failure and loss, underestimating skills and coping abilities, viewing energy as limited and easily exhausted, distorted causal explanations for successes and failures, and all or nothing thinking about progress and failure. The model I created is cyclical, explaining why the depressed individual may become “stuck” indefinitely.
An astute critic of my model may notice I did not include a path out of this cycle. While I’ll likely expand my model in the future, my goal at this time was to better understand the resistance of someone struggling with depression. However, my research suggests there are likely benefits to helping the client identify and challenge assumptions of their own inadequacy and the cost/inevitability of failure through the use of a variety of cognitive and behavioral interventions. These interventions may include cognitive restructuring techniques, activity scheduling, behavioral experiments, exposure therapy, goal setting, and problem solving training (see previous articles for more information).
Leahy’s Investment Model of Resistance is significantly more complex than the model I have created. I should also note that Leahy does not provide a visual representation of his model in Overcoming Resistance in Cognitive Therapy and I have attempted to simplify and approximate how the various factors described by his model may interact. For more information on Leahy’s model, I recommend purchasing his book. The version of Beck’s Cognitive Model of Depression was from Cognitive Behaviour Therapy Case Studies by Thomas and Drake. While I have not conducted any studies to assess the validity of my model, it is consistent with the anecdotal accounts of many people I have met who have struggled with depression, some of which provided direct, but informal feedback, about this model.
I would also like to note that by attempting to identify how the decision making of a person struggling with depression may contribute to maintaining that depression, I am not attempting to blame anyone and make them feel worse. In fact my intentions are to help expand our understanding of depression, so we can better understand and help those struggling with depression. By focusing on what we can control, and the consequences of the decisions we make, we are empowered to make positive changes in our lives.
Cognitive Behavioral Therapy is the most validated form of therapy for anxiety disorders. In a huge review of studies exploring the effectiveness of CBT, the researchers found “The efficacy of CBT for anxiety disorders was consistently strong” (click here for a link to a free copy of this study). In another comprehensive review of studies exploring CBT for generalized anxiety, the authors concluded “when compared to waiting list control groups, these treatments have large effects on worrying, anxiety and depression, regardless of whether effects were measured with self-report measures or with clinician-rated instruments” (click here for a copy of this study). Many people would prefer their anxiety just went away but research suggests few people who do nothing, reduce their anxiety. As the studies above suggest, one of the things people can do to reduce their anxiety is cognitive-behavioral therapy and at the core of CBT for anxiety is exposure therapy and behavioral experiments.
Simply put, exposure therapy involves exposing the client to their feared situations in a gradual, repeated, and prolonged manner until the client becomes desensitized. For example, if a client is terrified of public speaking they may work with their therapist to create a list of anxiety provoking situations (speaking in class, watching videos about public speaking, taking a class on public speaking, imagining speaking in public, speaking in a meeting at work, talking to a cashier at a store, doing a speech at Toastmasters, etc.). The client then ranks these situations from least anxiety provoking to most anxiety provoking, this is called an anxiety hierarchy. Then starting with a situation that does evoke some anxiety but is not overwhelming, the client would repeatedly expose themselves to these situations, over and over, until they become desensitized to this situation. A useful example of this most people can relate to is learning to swim as children. Many children are afraid or at least tentative about the water, but their parents encourage them to become more comfortable over time, often enrolling them in swim classes. As the child is gradually exposed to the water over time, they become less afraid. Alternatively, the children that are terrified of the water, and refuse to ever go in the water continue fear the water.
*For more information about exposure therapy see my article “Overcoming Anxiety and Avoidance” by clicking here, or download our free anxiety workbook by clicking here.
Behavioral experiments can take a number of different forms. Similar to exposure therapy, the client and therapist may work together to create a list of anxiety provoking situations. Then the client and therapist will work together to identify the client’s fears about what could go wrong in these situations. Often these fears are exaggerated and extreme but the client sees them as perfectly reasonable. So then we create a little experiment in which the client enters the feared situation and observes to see if their fears come true. Then the client runs the experiment several times in an attempt to gather more information. Once the client has run the experiment several times, they reconvene with the therapist to discuss what they have learned about their fears and their abilities to cope.
For example, perhaps one of the situations on the client’s anxiety hierarchy is saying “no” to other people. Perhaps the fear in this situation is something like “If I say no to my mother when she asks me to do something, she will call me selfish, the rest of my family will hate me, and I won’t be able to handle that.” So then the client and therapist run an experiment in which the client talks with their mother, explains they are trying to be more assertive and wants to work on saying “no” sometimes. Then the next time their mother asks them to give them a ride to the store, the client explains they cannot help that day due to other commitments, then observes what happens. In this situation, the client’s mother may very well call the client “selfish” and their family may complain, but the client also learns they can survive being called selfish and occasionally listening to complaints. Or perhaps the client’s mother understands the client has other commitments and they schedule a plan in which the client gives their mother a ride another time, or the client’s mother finds another way to the store. See the below table for an example how I would write-up a behavioral experiment assignment with a client.
Another type of behavioral experiment involves the client identifying what they suspect other people believe then conducting a survey to assess the accuracy of the client’s assumptions. For example, the client may believe that people believe that women over a particular weight are “unattractive.” Clients may start by simply ask some trusted friends or family about this assumption. They may take photos of themselves or others to friends or family and ask people about their impressions about the people in the photos. In this example, the client ideally learns that attractiveness is not directly related to something as arbitrary and simplistic as weight.
In my experience, exposure therapy and behavioral experiments have been immensely helpful for clients. Clients usually report dramatic shifts in their anxiety in only a short period of time. In CBT we assume the client becomes less anxious in situations they are exposed to because they learn that their initial assumptions about the dangerousness of the situation is exaggerated and their beliefs about their abilities to cope with the danger posed by those situations is minimized. In other words, their cognitions change. After exposing themselves to a variety of different situations, the client learns they have a habit of exaggerating danger and minimizing their abilities to cope, and so they become less anxious in other situations they have not exposed themselves too.
For example if you are anxious about travelling but you muster the courage to go to Mexico, you might learn that Mexico isn’t as dangerous as you expected. Then if you go to Germany you might learn that Mexico and Germany are safe. Then if you go to India you might learn that Mexico, Germany, and India can be travelled to safely. Then you might learn that travelling in general can be done safely, not only to those countries you have been to in the past.
One challenge in using exposure and behavioral experiments is explaining the importance of actually facing fears to the client. Some clients have spent decades avoiding situations that make them anxious and the thought of deliberately exposing themselves to these situations is terrifying. People tend to want to avoid situations that make them anxious. Unfortunately, it is this very avoidance which perpetuates the anxiety indefinitely.
Another barrier to effective exposure and behavioral experiments is called “safety behaviors.” Safety behaviors can sometimes resemble the compulsions of someone who struggles with OCD. Safety behaviors are unnecessary, excessive, or unhelpful activities or strategies people use in anxiety provoking situations to protect them from “something going wrong.” When the client is anxious about going to a new restaurant they may excessively research the restaurant online to create a plan to prevent something “bad” from happening. In this example the excessive research is the safety behavior the client uses to keep themselves “safe.” Then when they go to the new restaurant and nothing “bad” happens they convince themselves it is because they researched prior to going. In this situation, the client has not learned that they can safely go to a variety of different restaurants, but instead they have learned they can go to a restaurant when they excessively research it in advance. Other examples include holding glasses very tightly when you’re afraid of spilling, distracting yourself with your phone when afraid of standing in lines, and never disagreeing with people when you are afraid of conflict. Research suggests it is imperative safety behaviors are identified so the client can either avoid using them or gradually reduce the use of safety behaviors over time.
Sometimes a client’s anxiety is about situations to which they cannot be exposed. For example, the client might be terrified of earth quakes, someone dying, their son being in a car accident, getting fired, or being homeless. When the client cannot be directly exposed to their feared situations, we have got to get creative. We can watch videos of these situations, we can do research, we can read stories, we can write then recite our own stories in which the client is exposed to these situations, etc. This is based on the idea that thinking about the feared situation can actually desensitize the client. Some of these interventions are called “imaginal exposure.”
Research suggests CBT is an effective treatment for anxiety disorders. Exposure therapy and behavioral experiments are core elements of CBT for anxiety. By facing fears the client learns their feared situations are not as catastrophic as originally predicted and their ability to cope is better than expected.
The AWARE strategy can be used to reduce our distress we feel when we become anxious. The five steps of this strategy are:
Anyone that has tried to wrestle anxiety into non-existence can tell you this is not an effective long-term strategy. Fighting with anxiety is like holding a beach ball under water – the harder we push it down, the stronger it wants to pop back up. So our first step to reducing our anxiety is to first accept the anxiety, even though it is uncomfortable. Do not judge the anxiety as good or bad, instead simply acknowledge the physical sensations that you feel in your body.
Pay attention to your thoughts and physical sensations in a non-judgemental manner. You can rate your anxiety on a scale from 0-100, then watch it ebb and flow.
Continue to live your life despite the anxiety. Slow down if you have to, but stay in the situation and keep doing what you are doing. Continue to breath slowly. If you run from the situation your anxiety will go down, but your fear will go up. If you stay, both your anxiety and your fear will go down eventually.
Continue to accept, watch, and act until the anxiety dissipates. This will reduce your fear and you will learn to cope with your anxiety for future situations.
When we struggle with anxiety, we often catastrophize (predict a catastrophe will occur). We can challenge these catastrophized automatic thoughts by expecting positive outcomes. Expect some anxiety but also expect that you will be able to handle it and it will go down eventually.
The AWARE strategy comes from one of the most influential therapists in history Dr. Aaron Beck, one of the founding fathers of CBT. He details this strategy in greater detail in his 15th edition of “Anxiety Disorders and Phobias: A cognitive perspective.” Click here for a video of Aaron Beck and the Dalai Lama.
Personally, I have found the AWARE model helpful in both my own life, and in the lives of my clients. It combines the non-judgemental acceptance of the present moment of mindfulness approaches with the deliberate continuing to remain in the anxiety provoking situations of exposure therapy. When I was in school I would become anxious prior to having to give class presentations. I would sweat through my shirt and my body would shake uncontrollably. By accepting my anxiety and repeatedly giving presentations, I was able to reduce my anxiety over time. Now I routinely teach classes in front of dozens of students with only minimal anxiety. When we stop fearing our anxiety and avoiding anxiety provoking situations we can learn to trust ourselves and the world a little bit more.
Admittedly, it took me a long time to learn to listen to my fear. My earliest memory is from when I was three years old. My Mother, Father, little brother and I went to play in a local river. I did not recognize the danger and I fell into the water. I remember feeling helpless and confused and then my father saved me. Although I’m sure there were previous times, this was the first time I remember meeting fear.
As a man, I met fear on the top of a mountain with the whole universe watching. He greeted me as an old friend and embraced me with genuine warmth.
“What would my life be without you?” I asked.
“Why ask me that my son? Have I not protected you and guided you through all of the horrors in the dark?” he asked.
“I’ll admit there have been times when you have saved me from suffering and almost certain death, but I’ve noticed the times I have truly lived were the times I had the courage to ignore your warnings. When I have wanted to love, you warned me about humiliation and rejection. When I aspired to more, you took the air from my lungs and warned me about losing what I’ve got. And when I prepared to rest you made me uncomfortable and gave me fantasies about failure and suffering. But when I ignored you, I loved with my whole heart, I worked with passion, and I rested enjoying the present.” I explained.
Fear smiled with knowing sadness and replied “Even I am conflicted in this messy existence. I did indeed warn you of humiliation, rejection, loss, failure, and suffering. But, in those times of action and acceptance, I also spurred you forward with an even greater fear – a fear of dying without living.”
As a child I had to learn to listen to my fear. As an adult, I suspect I must learn when it should be ignored.
All counselling theories (narrative therapy, psychoanalysis, DBT, 
mindfulness based theories, CBT, etc.) all have underlying philosophies about how human beings “work”, what is “healthy”, and how people can remove barriers to become more “healthy.” People might be surprised to know there are a number of different variations of cognitive-behavioral therapy (CBT). One type of CBT is called Rational-Emotive Therapy (RET) and it was created by Albert Ellis. This article describes the underlying philosophies of RET and has been adapted from Bill Borcherdt’s book “Think Straight! Feel Great! 21 guides to Emotional Self-Control.”
RET is designed to teach people:
I suspect people will see some common themes in these recommendations. Generally, RET emphasizes personal responsibility and choice, it suggests that we are responsible for our emotional reactions and we can change our emotions, by changing what and how we think. RET also recommends we unconditionally accept our “self” while judging our emotional reactions as “appropriate” or “inappropriate”, which I think is an interesting idea. While I do not choose to use this terminology with my clients, I agree that intense emotions can interfere with our attempts to achieve our goals.
Most clients are resistant to making changes in their lives, usually for a variety of different 
reasons. People tend to want to minimize their choices and responsibility by suggesting they have no control over what they think or feel. There are several old videos of Albert Ellis working with clients on YouTube, and he has a very direct and almost confrontational style that I believe is reflected in the uncompromising philosophy of RET (click here for a classical example of RET at work). I’m not saying the advice listed above is bad advice, just that I suspect giving this advice in a way that clients could receive it non-defensively could take some tact.
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