Introduction to Cognitive Behavioral Therapy (CBT): Correcting the "Schema" Rules of the Mind

Overview of Cognitive Behavioral Therapy

Cognitive behavioral therapy is a form of psychotherapy that eases mental stress by working on cognition (how you perceive reality and see things), which affects your mood (emotions) and behavior.

For example, suppose you are a woman and you hear secondhand that a man, Mr. A, dislikes you. It is not uncommon to fall into extreme negative thinking, such as "Mr. B and Mr. C must feel the same way," even though no one actually said so. As a result, your spirits sink and you lose the energy for romance and socializing. Cognitive behavioral therapy aims to resolve psychological problems by finding this kind of extreme thinking, so-called "cognitive distortions," and rebalancing your thoughts.

In the 1960s, the American psychiatrist Aaron T. Beck proposed "cognitive therapy" as a psychotherapy for depression. Meanwhile, "behavior therapy," which tries to address emotional problems through behavior, had been developing since the 1950s. From the 1980s the two were increasingly integrated and used together, and clinical trials have shown their effectiveness for a variety of mental disorders.

Who It Is For

The theory, ideas, and techniques of cognitive behavioral therapy are used not only in psychiatric care but also in many other settings, including physical illness, lifestyle habits, occupational health, and education.

Focus on Four Aspects

The basic idea of cognitive behavioral therapy is the cognitive behavioral model (see figure below).

Common Foundation Manual for Cognitive Behavioral Therapy

(http://jact.umin.jp/manual/ pp. 11-14, last accessed October 20, 2023) Adapted from the above.

"Cognition" refers to the thoughts that come to mind when you encounter an event, and "mood" refers to emotions such as joy, anxiety, sadness, and anger. "Behavior" means what you actually do, and "physical symptoms" are the various symptoms that arise in the body, such as pain and fatigue.

For example, suppose a wife worked hard to cook her husband's favorite food, but on the next day off the husband left her with the kids and went out to play [Event]. The thought "My husband doesn't value my effort at all" comes to mind [Cognition], and sadness, anger, and loneliness spread through her chest [Mood]. After that, she does the housework while feeling resentful and conflicted, and hardly speaks to her husband [Behavior]. By night, stress gives her a bad headache and stiff shoulders, and she can't fall asleep [Physical symptoms]. Even when she tries to relax by watching TV or having tea, her dissatisfaction and loneliness toward her husband keep circling in her mind, and she grows more irritated and anxious. In this way, the four aspects influence one another, and it is not unusual for them to create a vicious cycle.

The cognitive behavioral model focuses on these four aspects. For proper treatment, it is important to organize and analyze the content of each one and how they connect, and to clarify the cause and background of the problem.

Cognitive Therapy and Behavior Therapy

Of the four aspects of the cognitive behavioral model, "mood" and "physical symptoms" are hard to control through willpower. Emotions such as the sadness and anger in the example above, as well as palpitations and headaches, are not problems that willpower alone can solve.

"Cognition," on the other hand, can be recognized, in the sense of noticing how you thought, if you pay attention to your thoughts, and that can become a clue for changing cognitive distortions and behavior. The same is true of "behavior." By changing how you think about and interpret things, you can change what you do.

The treatment approaches for these two are cognitive therapy and behavior therapy. Cognitive therapy works on ways of thinking. By correcting the cognitive distortions behind mental illness or distress, such as extremely negative or pessimistic thinking, it helps you think in a more flexible, freer way.

Behavior therapy, as the name suggests, aims to resolve behavioral problems. Suppose someone with panic disorder cannot ride the train. An approach that starts with a family member accompanying them on a walk around the neighborhood and gradually widens their range of activity is one example of behavior therapy.

Thoughts That Pop Up Instantly: "Automatic Thoughts"

You have a presentation tomorrow, and when someone asks how your preparation is going, thoughts like "What if it doesn't go well?" or "I'll probably fail" suddenly pass through your mind. Even if it wasn't a presentation, haven't you had a similar experience?

When something happens, thoughts and images sometimes come to mind instantly and reflexively, without any particular basis. These are called automatic thoughts. Various emotions arise along with automatic thoughts, and some kind of behavior follows.

It is perfectly normal for automatic thoughts to appear. The problem is their content. In depression and anxiety disorders, for example, extreme and negative automatic thoughts are common. If such a negative automatic thought happens to come true, it often deepens your conviction and traps you in a vicious cycle.

"Schemas" That Create Automatic Thoughts

Deep beneath automatic thoughts lies something like a core belief, called a schema (core belief). A schema is a kind of "rule of the mind" formed from past experiences, trauma, relationships, and experiences of success and failure. It gives your thinking certain patterns and habits. Schemas influence the generation of automatic thoughts.

Ministry of Health, Labour and Welfare: Cognitive Therapy and Cognitive Behavioral Therapy for Depression, Manual for Therapists

(https://www.mhlw.go.jp/bunya/shougaihoken/kokoro/dl/01.pdf p. 19, last accessed June 27, 2023) Adapted from the above.

In the example in the figure above, the person may simply be short on sleep or busy, but because of a negative schema, "I am unlovable," negative automatic thoughts arise in every situation. When someone is depressed, negative "rules of the mind" tend to dominate, and it has been shown that intervening in and correcting such schemas is effective for improving symptoms of depression and preventing relapse.