UCHealth, the not-for-profit health care system headquartered in Aurora, CO that includes hospitals and facilities throughout the state, in early 2023 offered a comprehensive look at cognitive behavioral therapy (CBT) as an intervention that can often help people of most any age address problems like anxiety, depression, insomnia, chronic pain, and social angst.
UCH consulted with clinical health psychologist Dr. Ava Schumacher, an expert in mind-body connections who cares for patients at the UCHealth Integrative Medicine Center in Denver. Information gained about CBT from Dr. Schumacher was reported online by UCH’s Katie Kerwin McCrimmon. This AgeWise article covers several key points made in that online report.
Cognitive behavioral therapy is a form of talk therapy that can be an alternative to taking sleeping pills, antianxiety medications or antidepressants. It can also be used to complement medications when they are prescribed. Dr. Ava Schumacher is a Denver-based clinical health psychologist who works with people who are struggling with a variety of difficulties, including medical challenges, chronic pain management, stress, anxiety, and sleep problems. She helps patients use the power of their minds to cope with health challenges and boost well-being.
“It’s essential to care for all aspects of ourselves — including mind, body and spirit,” Schumacher says. “I often integrate mindfulness and cognitive behavioral therapy into my work with patients.” UCH describes CBT as a specific kind of talk therapy that patients engage in with a trained mental or behavioral health professional. “Once people learn how to use CBT,” says UCH, “they can apply the strategies to many aspects of their lives, and the benefits can be long-lasting.”
Improve thinking to improve health
Schumacher adds: “The whole point of CBT is to gain a deeper understanding of the interconnectedness between our thoughts, behaviors and emotions and to understand how they affect each other and how we can make changes. A key goal of CBT is to change unhelpful thinking patterns into more helpful ones.” These in turn can enable people to change their actions and behaviors in a way that improves both mental and physical health.
Negative or depressed thoughts can understandably make people feel worse, affecting physical health. “It can be hard to change this cycle [of negative thinking] on our own,” Schumacher says. “If we’re already viewing things through a negative perspective, those thoughts tend to build on themselves. That’s where CBT comes in.”
CBT has been shown to work for a wide range of concerns, including anxiety, depression, stress management, sleep problems, chronic pain and improving self-confidence. “All of us have thoughts, emotions and behaviors,” Schumacher says. “Understanding how our thoughts relate to our emotions and behaviors can help us interrupt unhelpful patterns.” She notes that CBT can be used as a standalone intervention, or alongside other treatments, such as mindfulness and certain medications. It depends on each person’s unique history, circumstances, and the severity of their symptoms.
The phenomenon of “automatic thoughts”
“We all have automatic thoughts,” Schumacher goes on to say. “These are the thoughts that just bubble up in our minds without trying to consciously think a certain thing. And thoughts are not facts, but many of us tend to respond to our own thoughts as if they are facts, as we assume they’re true.” The trick, she says, is to be able to identify automatic thoughts and then objectively evaluate them for validity, instead of acting on them as if they were true.
As one example, suppose a person suffering from anxiety does not hear from a friend in an expected time frame. An automatic thought for the anxious person might be to assume they had done something wrong, offended the friend, and they might even conclude the friendship is on the rocks. They might go so far as to think it’s pointless to make friends. Whereas an easy going, non-anxious person would not jump to such negative assumptions and instead would consider logical reasons for the temporary lapse in contact.
This is where cognitive behavioral therapy comes in. “Often, our anxious and depressing thoughts are self-critical and self-blaming,” Schumacher says. “Sometimes you feel like you can’t get these thoughts out of your head, but CBT can help you learn to address these kinds of thoughts in a different, more helpful way.”
So is CBT just “thinking happy thoughts”? Absolutely not, Schumacher says. “We don’t just say, ‘think happy thoughts.’ We need to focus on and deal with what’s really going on. It’s not useful to deny reality. But there usually are multiple ways to think about any given situation, and we want to make sure we’re seeing things as accurately and in as helpful of a way as possible.” Part of that is recognizing unhelpful thought patterns when you don’t realize you have them.
The role of “cognitive distortions”
Automatic thoughts very often generate negative thinking. This is turn can trigger cognitive distortions. UCH describes these as patterns of thinking, mental filters or biases which lead us to have inaccurate and oftentimes overly negative thoughts. “The mind is often more likely to focus on negative aspects of a situation,” Schumacher says. CBT can help people recognize these thinking traps and reframe their perspective.
Examples of cognitive distortions listed in the UCH report include the following:
- Black-and-white or all-or-nothing thinking — Seeing a situation in only two categories, rather than shades of grey. (If I don’t ace this test, I’m a failure.)
- Catastrophizing — Assuming that a situation will turn into a giant problem or a catastrophe, jumping to often disastrous conclusions. (I can’t believe it’s 3 a.m., and I still haven’t fallen asleep. I will never get a good night’s sleep again.)
- Emotional reasoning — Believing something is indeed true based on strong feelings. (I know I do a lot of things well, but I still feel like a failure.)
- Mind-reading — Believing we somehow know what others are thinking (I just know he doesn’t like me).
Black-and-white assumptions and catastrophizing are really common, Schumacher says. And of course they end up making people feel worse. “With CBT, people learn how to recognize these inaccurate, unhelpful cognitive distortions and come up with alternative, more balanced, helpful ways of thinking.” It’s crucial to actually look at the evidence and ask: “What is really going on?” The goal is to arrive at balanced, realistic thoughts.
People facing a devastating diagnosis or a tragic life event, for instance, can think of it in two distinct ways. The less helpful (but perhaps instinctive) response might be: “This is absolutely terrible, the worst thing that has ever happened to me, and I can’t deal with it.” A more helpful and balanced approach might be: “This is a tragedy in my life, and though it will be difficult, I will find a way to get through somehow.”
UCH’s report addressed a number of specific questions about CBT. Here are some of those.
How long does CBT take — i.e., how many sessions?
“We usually try to help people in about five to 15 sessions in our clinic,” Schumacher says. “Our goal is to teach people the skills to help themselves develop more helpful habits and ways of thinking. My goal is that eventually you won’t need to come see me anymore because you will have learned how to implement new skills on your own.” She notes patients in some cases can successfully use CBT techniques during short-term therapy for whatever stressor(s) they are facing.
Do relaxation techniques work well with CBT?
Yes. Relaxation training is a common component of CBT, and it can be very helpful in calming the mind and reducing the effects of stress on the body. One of the most common relaxation techniques is deep breathing, which you can build into your daily routine and/or practice when you feel you are falling into spirals of negative thinking. A simple deep-breathing method is to follow these steps in sequence: 1) Let your breath naturally flow deeply into your body, expanding the belly, without forcing it; 2) Inhale for about a count of five; 3) Pause briefly after the inhale; 4) Exhale for about another count of five, slowly and gently releasing the breath; 5) Pause again briefly after the exhale, before taking the next breath.
Other suggested relaxation techniques include the following:
- Take a walk or engage in another form of exercise.
- Take a bath.
- Read a book.
- Spend time with your pet.
- Call a friend.
- Consider avoiding screen time and social media as they may not be restorative.
Is “avoidance” a good way to reduce stress? And how does CBT fit in here?
The answer to the first is ultimately No. Avoiding something that challenges us may seem to reduce stress in the moment, but in the long term, it usually makes it worse. “The longer we try to avoid something, the scarier it can become,” Schumacher says. CBT helps people sort out their thoughts and consider why they might be procrastinating or avoiding difficult tasks. Then they can challenge their beliefs about the situation and make plans to act. “The more we face our fears in safe, supportive, planned ways, the more comfortable we can become,” Schumacher says.
Can CBT help with insomnia problems?
There’s actually a specific type of CBT for insomnia known as cognitive behavioral therapy for insomnia or CBT-I. “CBT-I is the first-line treatment for insomnia, and it can be very effective,” Schumacher says. “It generally produces better, longer-lasting results for insomnia than sleeping pills.” She notes she often helps her insomnia patients start first with behavior changes. This includes creating a good environment for sleep, also known as “sleep hygiene.” E.g., sleep in a cool, quiet, dark room; avoid exposure to screens (TV or computer); keep the phone at a distance; don’t have your bed double as a work space for your laptop. It also helps to avoid intense exercise, big meals or alcohol consumption shortly before going to sleep, and try to maintain a consistent sleep schedule. If your mind happens to be racing at bedtime, try meditating or other relaxation techniques. Some do well with white noise.
Insomnia often leads the sufferer to anger and agitation, including an “automatic thought” or “cognitive distortion” that the insomnia cannot be cured. It’s another reason why the thought reframing of CBT can be helpful in minimizing the anxiety and frustration of insomnia.
Can alcohol, marijuana or cannabidiols (CBDs) help with sleep?
“Marijuana and CBDs can certainly help some people fall asleep. So, they can be helpful in the short term,” Schumacher says. “But they also can affect the quality of sleep. Over the long run, using marijuana for chronic insomnia can lead to poor quality of sleep. That can also be true for sleeping pills.” Research shows CBT can be much more effective in helping people get higher-quality sleep and longer-lasting results compared to those who rely on CBDs or other marijuana derivatives to help them sleep. One reason, according to Schumacher: “CBT-I gets to the root of the problem. Let’s tackle the thoughts and beliefs that are getting in the way of good sleep.”
Can CBT work for pain management?
The UCH report observes that pain is both a sensory experience and a mental/emotional experience. “While psychologists can’t erase the physical experience of pain,” UCH states, “they can help people reframe how their minds handle the pain to improve coping, daily functioning, and overall quality of life.” Or as Schumacher notes: “The way you think about pain can help you cope with it.”
Schumacher says, “Sometimes patients worry that seeing a psychologist for their pain means that their doctors or the psychologist doesn’t believe the pain is real, or that they’re making it up. [But] the pain is absolutely real.” And our nervous system and the process of pain perception is very complex. The way we think about pain and the behaviors we use to cope with pain can have a strong impact on the overall experience and impact of pain in our lives.
Schumacher says CBT can be a highly effective component of treatment for chronic pain. The therapy is often used alongside other interventions ranging from medications to physical therapy to surgery, depending on the patient’s health condition and type of chronic pain. “In some instances, CBT can work better for chronic pain than medications like opioids,” she says. While there are certainly many people who also benefit from opioids or other pain medications, Schumacher says it’s common for people who use pain medications to develop a tolerance over time that reduces the effectiveness of pain pills. For some this opioid use can be linked to worse pain over time.
How committed to CBT must a patient be for the therapy to be effective?
Schumacher’s reply: “CBT is a very active treatment. It’s not like a doctor prescribes a pill, and you take it” and that’s it. “CBT should be a very collaborative process. You set goals during your therapy sessions, then you need to put CBT into practice in your day-to-day life.”
She adds that you can, with some guidance, learn CBT techniques on your own, but it’s easier to learn how to use CBT when you’re working with a pro. “CBT is best delivered through a trained, licensed mental health professional. An expert can help you see things in a new light and ask the right questions. They are like a mirror to you so that you can get fresh perspective,” Schumacher says. They also can determine whether CBT or another type of talk therapy will be most helpful.
It is vital, she adds, to work with a behavioral health expert whom you can trust. “Having a good match is a critical ingredient for therapy to be effective. If you don’t gel with someone, it’s totally OK to move on.” However, she also notes that it can be difficult to find psychologists or therapists who are accepting new patients now. (UCHealth patients can access behavioral health experts through many primary care clinics.) There is also a listing of CBT professionals practicing in Colorado at https://www.psychologytoday.com/us/therapists/colorado?category=cognitive-behavioral-cbt.
If you’re waiting to get in with an expert, or you want to sample some skills that you can learn through CBT, Schumacher recommends starting with relaxation techniques or reading more about CBT. There are many different CBT-focused books and resources that are tailored to specific concerns people may have. She recommends “The Little CBT Workbook” for those interested in a general approach to CBT. For people experiencing chronic pain, she says she likes the book, “Managing Pain Before it Manages You.”