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

An overview of cognitive behavioral therapy

Cognitive behavioral therapy is a form of psychotherapy that eases mental stress by working on cognition (how we take in reality and see things), which affects our mood (feelings) and behavior.

For example, if you are a woman and hear secondhand that a man, Mr. A, dislikes you, you may often fall into extreme negative thinking: "Mr. B and Mr. C must feel the same," even though no one told you so. As a result, you feel down and lose the energy for romance and socializing. Cognitive behavioral therapy aims to solve mental problems by finding such extreme thinking, so-called "cognitive distortions," and rebalancing the way you think.

In the 1960s, the American psychiatrist Aaron T. Beck proposed "cognitive therapy" as a psychotherapy for depression. Meanwhile, "behavioral therapy," which tries to address emotional problems through behavior, had been developing since the 1950s. From the 1980s, the two were 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, such as physical illness, lifestyle habits, occupational health and education.

Focusing 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

(Created based on http://jact.umin.jp/manual/ pp. 11-14, last accessed October 20, 2023)

"Cognition" is the thought that comes to mind when something happens; "mood" is an emotion such as joy, anxiety, sadness or anger. "Behavior" is actually doing something, and "physical symptoms" are the various symptoms that arise in the body, such as pain or fatigue.

For example, say a wife worked hard to cook her husband's favorite dish, but on his next day off he left the children to her and went out to have fun [event]. The thought "My husband doesn't value my efforts at all" comes to mind [cognition], and sadness, anger and loneliness spread through her chest [mood]. Then, feeling patient but conflicted, she does the housework and barely speaks to her husband [behavior]. At night, stress makes her headache and stiff shoulders worse, and she can't fall asleep [physical symptoms]. She tries to relax by watching TV or drinking tea, but her frustration and loneliness toward her husband keep circling, making her even more irritated and anxious. In this way the four aspects affect each other, and it's not unusual for them to create a vicious cycle.

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

Cognitive therapy and behavioral therapy

Of the four aspects of the cognitive behavioral model, "mood" and "physical symptoms" are hard to control by willpower. Emotions like the sadness and anger in the example above, or palpitations and headaches, can't be fixed by willpower alone.

"Cognition," on the other hand, can be recognized if you pay attention to your thoughts, and that can become a starting point for changing distorted thinking and behavior. The same goes for "behavior." By changing how you think about and take in things, you can change your behavior.

The treatment approaches for these two are cognitive therapy and behavioral therapy. Cognitive therapy works on the way you think. By correcting the cognitive distortions behind mental illness and difficulties, such as extremely negative or pessimistic thinking, it helps you think more flexibly and freely.

Behavioral therapy, as the name suggests, aims to resolve behavioral problems. Imagine a person with panic disorder who can't ride trains. Starting with a family member walking with them around the neighborhood and gradually widening their range of activity is one example of behavioral therapy.

Thoughts that pop up in an instant: "automatic thoughts"

The day before a presentation, when someone asks how your preparation is going, thoughts like "What if it doesn't go well?" or "I'll probably fail" flash through your mind. Even if not a presentation, have you had a similar experience?

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

Having automatic thoughts is perfectly normal; what matters is their content. In depression and anxiety disorders, for example, extreme and negative automatic thoughts are common. If such negative automatic thoughts unfortunately come true, people often fall into a vicious cycle of becoming even more convinced of them.

"Schemas" that create automatic thoughts

Deep beneath automatic thoughts lies something like a core belief, called a schema. Schemas are "rules of the mind" formed from past experiences, trauma, relationships, and successes and failures. They give our thinking particular patterns and habits, and they influence what automatic thoughts arise.

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

(Created based on https://www.mhlw.go.jp/bunya/shougaihoken/kokoro/dl/01.pdf p. 19, last accessed June 27, 2023)

In the example above, the person may simply be short on sleep or busy, but because of the negative schema "I am unlovable," every situation produces negative automatic thoughts. In depression, 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 and preventing relapse.