cognitive restructuring | Dr. Gerald Stein

What does psychotherapy do and how does it do that? Good questions, and even some therapists might have a hard time answering them. Of course, some of the goals are obvious: reduce depression, have better relationships, eliminate anxiety, enjoy your life more, and stop worrying. But what are the elements that get you there? I’ll give you a sense of some of the factors that permit those goals to be achieved.

1. Trust. Many people entering treatment have trust issues: they trust too easily or not at all, usually the latter. Trust will start with the relationship between you and the therapist. Simple things: does he listen? Does he understand? Does he seem interested and dedicated? Is he dependable? Does he care? If the answers to these questions are “yes,” then it will be a bit easier to begin to trust others. The experience of a benign relationship with one person can open you to the possibility that this experience can be achieved elsewhere in your life.

2. Validation. Many people coming into psychotherapy having been told that they should “get over it,” that they “shouldn’t feel that way,” that they shouldn’t complain or “whine;” or having been ignored, dismissed, or criticized too often when trying to express themselves. Some folks believe feelings are unimportant; others might state that it is not “masculine” to feel too much, and so forth. As a result, many new patients have so buried their feelings that they are alienated from themselves and don’t know whether it is appropriate to think or feel as they do. A good therapist creates a safe place for talking about such things (trust again), and gives the person a sense that there is value in what they feel and think. Over time, this action, by itself, can help improve self esteem and reduce sadness and alienation.

3. Grieving. If one has not had supportive relationships (with people who are both trustworthy and validating), the sense of loss or absence contributes to sadness, and sometimes to depression. The relationship with the therapist allows you to express the emotions related to loss (both sadness and anger) to someone who listens patiently and shows concern. As you process those feelings of loss, your sadness should gradually diminish. The therapist serves as a witness and again, as someone who validates your pain. Grieving in isolation too often contributes to the feeling of disconnection and alienation from the world. Grieving with someone who cares reconnects you to one of the things that can be good in life: human contact.

4. Learning new things. Any good therapist needs to provide some guidance and tools that enable change. This might come in the form of helping you learn and practice new social skills (including acting these skills out with the therapist), assisting you in changing how you think (cognitive restructuring) that helps you reduce self-defeating thoughts, training in how to be assertive (again with role playing in the therapy session), or meditation.

5. A change in perspective. A good therapist will provide you with new ways of thinking about the world and about your life. Since he can see you from the outside, he is more likely to see you in a way that you cannot see yourself.

6. Facing things, not avoiding things. We all practice avoidance some of the time, and some of the time it is a useful thing. Unfortunately, many of us practice it all too much. We distract ourselves from pain and avoid challenging situations. We can use food, TV, shopping, sex, drugs, alcohol, the internet, and computer games to get us away from whatever it is we can’t handle. We worry about problems rather than coming up with a plan of action and taking them on. We don’t ask out the pretty girl for fear of rejection, or say “no” to people who want to befriend us for the same reason. We stay at a “dead-end” job because of our insecurities. And, of course, unhappiness is the result.

A therapist can assist you in identifying the patterns of avoidance, help you to gradually become able to tolerate anxiety (by use of such things as cognitive restructuring, role playing or meditation) and give you tasks that gradually increase in difficulty so that you reduce avoidance and begin to take action that works.

7. Acceptance. By acceptance I am referring to acceptance of the nature of life and the discomfort that comes with living; acceptance of the fact that being open to life allows you to experience satisfaction and joy, but also opens you to pain; and awareness of the temporary nature of most of that discomfort. The more that you take life on its terms, the less you will be trapped by it.

Remember playing with the Chinese Finger Puzzle as a kid, the cylindrical woven structure made of bamboo, open at both ends? You put your two index fingers into it, but when you pulled hard to get your fingers out, you became more stuck. Only by releasing the tension and moving your fingers toward the center of the device, did it collapse and no longer held you tight. Life is a lot like that to the extent that we must stop engaging in behaviors that only make us more “stuck.”Acceptance allows you to free yourself, at least somewhat, from what is distressing about life.

8. Valued Action. If you are caught in the struggle with your emotions, or focused on avoidance of pain, what is good in life will be hard to achieve. Therapy can help you to think about the life you would like to lead, the life that is consistent with your values, and help to relieve you of the habits that keep you so wound-up that you don’t have time to think about what it is you would really like to do, and what it is that would lead you to a sense of satisfaction and accomplishment. What is your true self? Therapy can help you find out and encourage that person to exist in the world.

The description I’ve given you is based, in part, on my experience in life and training, especially training in such therapeutic approaches as cognitive behavior therapy (CBT), mindfulness-based behavior therapy, Acceptance and Commitment Therapy (ACT), and psychodynamic psychotherapy. Other therapists may have a different view of what is important and how to help you get to the point that your life is more satisfying and less fraught with depression, anxiety, or chronic relationship problems. But here, at least, I hope that I have given you some sense of direction and some reason to be hopeful about the possibility of change in your life.

Social anxiety isn’t unusual. Since you are reading this, you might well be wondering whether your own experience of anxiety (or that of someone you love) constitutes a Social Anxiety Disorder.

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), such a condition exists when someone experiences a “marked and persistent fear of one or more social and performances situations in which the person is exposed to unfamiliar people or possible scrutiny by others. The person fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.”

The essence of this condition is a preoccupation with what others might think of you.

Now, we all are concerned with this some of the time.

Think of hoping to get a job promotion or wanting to impress a potential romantic partner. But consider the language of the diagnostic manual carefully, especially the words “marked and persistent fear.” One hallmark of this disorder is avoidance. When the anxiety is so great that you do your best to get out of doing something (e.g. asking someone on a date, giving a speech, attending a party, returning an item to the store, etc.) then you very well may have a clinically significant condition that can benefit from treatment. In effect, you are trying to avoid both the uncomfortable situation and the feelings that you believe will come with it.

In addition to avoidance, the individual will commonly be aware that his fear is greater than that which would be experienced by most people in a similar set of circumstances, and that the condition is very distressing and/or interferes with his life in significant ways. In fact, one of the ways that Social Anxiety Disorder complicates one’s life is by making it difficult to do the things and have the relationships that would make that life interesting, enjoyable, and fulfilling.

Is it hard to take a compliment, be the center of attention, or talk to a stranger? Do you worry what others will think of how you look and sound? Is it hard to be spontaneous in a conversation and are you too distracted by your own worries to fully concentrate on what the other person is saying? Do you get tongue-tied when trying to make an impression or have the sense that your voice is quivering or that you are perspiring too much?

Do you hesitate to state a strong opinion for fear of sounding stupid or being rejected for your ideas? Do you try to prevent others from getting to know you very well because you believe they will eventually conclude that you are inadequate and reject you? These kinds of preoccupations are typical of Social Anxiety Disorder.

The good news is that with persistence, an accomplished therapist, and the right program of treatment, you have an excellent chance of significant improvement. On the order of 80% of those who receive a systematic cognitive-behavioral (CBT) program will likely experience such change.

A good CBT counselor first makes sure that social anxiety is your major problem. For example, its not unusual for people with a Social Anxiety Disorder to have had one or more panic attacks. If those episodes occur outside of social or performance situations and lead the person to focus on their physical health, they likely indicate that a Panic Disorder is present and that the panic itself should be the focus of treatment.

However, about 50% of people who have clinically significant social anxiety also have had panic attacks. Therefore, if your preoccupation is more about how you look to others and what they think of you than it is about the symptoms of panic, treatment is likely to target your social issues.

CBT assumes that bodily sensations (such as shakiness, blushing, or a lump in your throat), behavior (such as having difficulty making eye contact or avoidance), and thoughts (such as the belief that others will reject you or that you will lose your job) all interact to fuel your social anxiety problems.

Thus, for example, the more your thoughts focus on the belief that you need to be perfect or the likelihood that you will fail, the more you are likely to experience physical manifestations of your anxiety and behave in a way that betrays your insecurity. As a result, CBT attempts to help you change physical symptoms, behavior, and cognitions.

A good cognitive behavior therapy program for social anxiety will help you learn to counter irrational thoughts that tend to be self defeating (this is called cognitive restructuring), and gradually practice with the therapist (this is called role playing) those situations that are difficult for you, beginning only with those that produce a relatively small amount of anxiety, and then try out your new skills in the real world, again beginning with relatively easy kinds of social interactions and working toward the ones that are harder for you.

And, you will discover that if you can tolerate small amounts of anxiety rather than flee them, you will “habituate” to the anxiety in much they way that your nose adapts to a foul odor by adjusting so that after a short amount of time the smell is not nearly so strong; similarly, your anxiety will weaken if you stay in the uncomfortable situation, usually within 45 minutes.

Treatment typically takes somewhere in the neighborhood of three to four months, although it can take longer if other issues also need attention. When it is successful, the patient usually finds himself less troubled by physical symptoms, more assertive, less preoccupied with other people’s opinions, more optimistic, less awkward, able to receive compliments without discomfort, able to look people in the eyes, and less avoidant.

It can feel enormously freeing and lead to much better things in life, including more and better friendships, greater vocational success, and a more satisfying romantic life.

Persistence is essential and the program takes some courage. But if you want to change your life and be less encumbered by social anxiety, CBT for Social Anxiety Disorder has much to offer.

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