I am a combat and disabled veteran, retired military officer, and licensed professional counselor with over 30 years of experience and education in clinical psychology and cognitive-behavioral therapy. I was an Assistant Professor of Behavioral Sciences and Leadership and counselor at the United States Air Force Academy from 1988 to 1993 and am author of the future New York Times Best Seller: You Think, You Are…Anxious: A Journey from Avoidance to Acceptance, the first installment in the You Think, You Are series. I will bestow my knowledge and wisdom, a proprietary approach to cognitive-behavioral therapy known as Body-Mind-Behavior Therapy (BMBT), in the first of the series, which follows forthwith.
The earliest cognitive-behavioral therapists lived thousands of years ago and the origins of cognitive-behavioral psychology go back as far as Buddha (563-483 BC) who said, “We are what we think; we are shaped by our thoughts; we become what we think.” Actually, he said it in Chinese, because his English was not great. Confucius (551-479 BC) also pointed out (in Chinese, of course) the importance of thoughts and mindfulness in behavior, when he said, “The more man meditates upon good thoughts, the better will be his world and the world at large.” How about that! Those two guys were pretty smart because, here we are two thousand five hundred years later and, we have only recently rediscovered the validity and usefulness of these profound statements.
Wait a minute; did he say he was a future New York Times bestselling author? Bestow his knowledge and wisdom? What? Is he nuts? Some might think so, but I prefer to think of myself as mildly eccentric. But, think about what Buddha said for a minute: “We are what we think” (hence, the title of this book and series). It is so true, but we take it for granted that sometimes, many times, in fact, that what our minds tell us is far from reality, yet the majority of the time we believe exactly what our thoughts tell us, even though our thoughts may not be, and probably are not, true. Scientists say that we have as many as 50,000 thoughts a day. If we knew how accurate our memories actually are at remembering things correctly, we would be hesitant to believe anything that goes through our minds. The mind is a very funny thing as we shall see as we progress in our “Journey from Avoidance to Acceptance”.
How many times have you been absolutely sure something was true, but it turned out not to be the case (or vice versa)? “I’m going to get really nervous during that upcoming presentation and forget what I’m supposed to say.” “What an idiot I am.” “Those people are laughing at me because I’m fat.” Is what you think is reality or are they just thoughts? What goes through your mind could possibly be true, you could get nervous, freeze, and forget what to say in front of a bunch of people, but it most likely would not happen, had you not given those doubts credibility in the first place. Nevertheless, you believe the thoughts anyway, making yourself more nervous than you probably need to be, a self-fulfilling prophecy of sorts. Because you think you will get nervous, you, in fact, become nervous which, in turn, negatively affects your performance, making you even more nervous. That is what we call “meta-cognition”, which can be defined as “thinking about thinking” (cognition originates from the Latin verb cognoscere, literally meaning "to know") or, in this case, getting nervous about getting nervous, and it is ruining your life! It is also an excellent example of a vicious cycle, a cycle which, if not interrupted or broken, can escalate out of control into severe anxiety or full-blown panic.
So what are you going to do about it? Well, you can do nothing about it and be miserable for the rest of your life, or, you could try to sort things out on your own, maybe read a self-help book (like this one), or you can get some help from a professional counselor. Cognitive behavioral therapy (CBT) is the most widely researched mode of psychotherapy and efficacious (that is scientist talk for “effective”), particularly when it comes to anxiety and depression. But, what exactly is CBT? Well, I am going to tell you, the way I understand it, and introduce you to my approach to cognitive behavioral therapy, what I call Body-Mind-Behavior Therapy or BMBT, for short.
BMBT is a cognitive behavioral approach, in that we focus on thoughts and behaviors, but is different to traditional CBT, in that with BMBT, we focus on changing the context of thought rather than the content. That might not make much sense right now, but I am going to explain it to you in simple English (not Chinese) and in “un-”scientific terms, but first we need to know how we got here . . . a little history perhaps.
Behavior therapy got its start in the 1920s and 1930s, but really took off in the 50s when Joseph Wolpe designed a method called systematic desensitization. In the late 1950s and early 1960s, Albert Ellis and Aaron Beck began what we call cognitive therapy today, a therapy where negative automatic thoughts (aka NATS – like those annoying little buggers that swarm around your head on a hot summer day and drive you nuts, but spelled slightly differently) are analyzed, challenged, and tested. Because their methods contained behavioral elements as well (exposure, activity scheduling, and so on), the therapy has commonly become known as cognitive behavioral therapy or CBT for short. In the 1980s, along came the "third wave" (as Steven Hayes and others have called it) of cognitive behavioral therapy. Dr. Marsha Linehan developed a therapy called Dialectical Behavior Therapy (DBT) for the treatment of borderline personality disorder at the University of Washington and Steven Hayes developed what is now known as Acceptance and Commitment Therapy (ACT - pronounced like the word, not as an acronym) at the University of Nevada in Reno. Both DBT and ACT incorporate "mindfulness" and "acceptance" into CBT, hence the tag "third wave" which has become associated with these evolutionary and revolutionary new treatments. MBMT (BMBT??)incorporates the best of CBT, DBT, and ACT into a powerful, yet extremely simple package, a package that is deceptively basic and drastically different than anything you have ever tried before. Are you getting excited yet?
Well, don’t get too excited just yet because here is the bad news. People in general, and Americans in particular, spend a lot of time (and money) being anxious and depressed. According to the National Institute of Mental Health (NIMH), some 40 million American adults, 18 percent (nearly two (2) out of every ten (10) people), suffer from an anxiety disorder in any given year. The anxiety disorders include specific phobias (like acrophobia – fear of heights – accounting for 8.7%), social anxiety disorder (fear of people and being evaluated – public speaking anxiety is an example - 6.8%), post-traumatic stress disorder (PTSD – a devastating disorder, resulting from a severe trauma – making up another 3.5%), generalized anxiety disorder (excessive worry - 3.1%), panic disorder (strong, urgent anxiety attacks that come out of the blue - 2.7%), obsessive-compulsive disorder (or OCD – hoarding, excessive checking, or fear of contamination are examples - 1%), and, finally, agoraphobia (fear of open spaces – more accurately, the fear of having a panic attack when away from home - often found with panic disorder - coming in at .8%). If that were not bad enough, another 9.5 percent of the U.S. population, age 18 and older, (nearly one out of every ten people), has a mood disorder, like depression or bi-polar disorder, in any given year according to the NIMH. These disorders (illnesses, problems…pick a label) cost millions, if not billions, of dollars each year in therapy, visits to general practitioners, medications (can you say Zoloft?), and lost productivity, including missing work.
Now for the good news. The anxiety and mood disorders we have been talking about can be treated quite effectively with CBT, DBT, ACT or, in this case, BMBT. As a matter of fact, the vast majority (nine out of ten) of the "well-established" empirically supported treatments (according to the American Psychiatric Association) for the anxiety and mood disorders are cognitive-behavioral. In simple terms, CBT works very well for many problems, anxiety and depression in particular. Over the next several chapters, I will be describing BMBT in much more depth, taking a lot of the mystery out of psychotherapy and dispelling many of the myths that surround it. If you have seen the show Obsessed on A&E, a show about OCD and CBT, you have a very rough, and I do mean very rough, idea of how cognitive-behavioral therapy works, at least for people with OCD. I will now give you a brief glimpse of what is to come in upcoming chapters.
I will start by providing a historical overview of where cognitive behavioral therapy has been, and where it is going, looking at some of the philosophies and theories behind cognitive behavioral therapy as it has evolved and how it exists today. I will briefly discuss B.F. Skinner, Albert Ellis, Aaron Beck, Marsha Linehan, Steven Hayes and the tremendous contributions these incredibly talented individuals have made over the past half-century as well as the theories behind their successes. It is important to know where you have been, at times, to have an idea of where you are going, and the people I mentioned, and their theories, are at the forefront of psychotherapy today. Notice I did not say “cognitive behavioral” psychotherapy, I said “psychotherapy” in general, because the cognitive behavioral therapies are the most studied, effective, and widely used of all therapies in existence.
I will then elaborate on mindfulness and acceptance, both of which are the key to successful treatment, particularly for anxiety. Mindfulness has been integrated into cognitive behavioral therapy by asking clients to focus on the here-and-now, using techniques derived from Zen Buddhism. Mindfulness is not a spiritual process in the sense that it is associated with any particular religion (as it is used in DBT, ACT, and BMBT anyway ???), it is a state of mind which allows the client to maintain contact with the present, allowing him or her to accept thoughts, memories, and emotions as they are, without judgment. This is a powerful method of reducing anxiety and other painful psychological problems, and is something I strongly encourage my clients to try. Personally, I find no conflict between mindfulness, acceptance, and my faith, but that is a judgment you will have to make for yourself. Cognitive behavioral therapy can work quite well without the mindfulness component, but I believe you will be short-changing yourself if you ignore it. You can find a series of mindfulness exercises on the accompanying CD, along with several other resources we will be talking about later, making this an extremely user-friendly experience and complete package, one-stop shopping for your psyche, if you will.
Next is “dialectical” thinking, the cornerstone of Linehan’s DBT and a philosophy I embrace in BMBT. The dialectical philosophy is too complex to explain here, but basically entails looking at things in terms of shades of “grey”, getting away from “black and white” or “dichotomous” (all or nothing) thinking many of us tend to gravitate toward. The primary dialectic Linehan teaches is “acceptance versus change”, where the therapist accepts the client (and the client accepts her/himself) as he/she is in the here-and-now, validating any problems and struggles, while pushing him/herself to change for the better. It is not the therapist that challenges thoughts or makes the decisions, it is you, the client (or reader), that makes the decisions, with expert assistance from a professional counselor, or in this case, my book.
There are four primary factors involved in mental health (or mental disorders), factors that can become a “vicious cycle” when they get out of whack and left unattended. The four factors I am talking about are physiology (BODY -biochemical imbalances, diet, sleep, exercise), cognition (MIND – like those nasty, annoying NATS), behavior (BEHAVIOR - smoking, overeating, drinking), and affect (or emotions, a combination of BODY, MIND, and BEHAVIOR). If any one of these domains becomes unstable, it can throw the whole system out of balance, resulting in anxiety, depression, or some other psychological problem.
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| Figure 1 |
As a matter of fact, the logo on the front and back covers (Figure 1), which I created for my practice in Kansas City, includes the Greek letter "psi", representing psychology, and the circular blue arrows surrounding the symbol represent the physiological (BODY), cognitive (MIND), behavioral (BEHAVIOR), and emotional (BODY + MIND + BEHAVIOR) components of the human psyche. As I alluded to earlier, those four components constantly interact to make you sad or anxious, a “vicious cycle”, or happy and serene, what I like to call a “precious cycle”. I will address each of these factors separately, and in detail, so you understand how they can affect you and what you can do to help them work in harmony.
Life skills are skills that make it easier to navigate life, even when anxious or depressed, and are skills everyone can benefit from understanding and practicing. We already mentioned one of them and that is mindfulness. The others are distress tolerance (stuff you can do when things get rough), interpersonal effectiveness (how to get along with others and stand up for yourself at the same time), and emotional regulation (tools you can use to feel less stressed). These really are very simple tools, but you will be surprised by how easy it is to forget how to use them when you are feeling stressed, anxious, or worried. I will explain how to recognize and use these tools, when appropriate, to help you be more effective in life and content in the present moment.
I will then address the biggest threat to mental health in general, and the crux of the anxiety disorders: avoidance. Avoidance takes many forms, but some of the most common are smoking, overeating, excessive drinking, drug abuse, and sexual (and other) addictions (can you say video games???). But are those not behaviors (you are probably asking yourself)? Yes, they are behaviors, avoidant behaviors, because they help you avoid the things that are really bothering you, like those nasty NATs that are contributing to your anxiety and/or depression. You can, and do, also avoid thoughts, physical sensations, emotions, and other “internal” behaviors. In short, avoiding what you are afraid of, or find distressing is what causes and perpetuates anxiety (and depression).
Now that we have a solid foundation, the real work begins! I will next take you through a series of steps (chapters) using experiential techniques and exercises while explaining the intent of those techniques and exercises in simple terms, something Steven Hayes would probably argue against doing, but that I believe is essential when dealing with intelligent, thoughtful human beings.
We will first review all of the things you have tried, to control anxiety over the years, but have obviously failed at, or you would not be reading this book. As I mentioned earlier, control is the problem, not the solution. It seems somewhat counterintuitive and it is, because, again, as I told you earlier, my approach is unlike anything else you have tried before. What you have been doing does not work, so how about taking a radically different approach? What some might call “thinking outside the box”.
We will then determine how you view yourself and offer some alternatives, giving you a solid foundation on which we can build a totally same you. Same? Not new? That is correct. There is nothing wrong with you, nothing broken. You have simply learned to think the way you do, the way that makes you anxious, and you can learn to think in a way that does not make you anxious.
Next, we will try some things that will give you a new perspective on anxiety and emotions. You will experience a new way of thinking about your thoughts, sensations, behaviors, and emotions, focusing on the context rather than the content, a deceptively complex, yet simple alternative to the way you have been doing it for so long.
The next step in the process will be to look very hard at your values. Not the values you think you should have because your mother or partner wants you to be a certain way, but the values that are important to you. To put it simply, those which would be important to you if you knew that nobody else would know what those values are. Once you determine your true values, and I am not talking about hardware, setting specific goals based on those values and committed actions, is the obvious next step. By having a clear guide, goals that are based on your values, and making a commitment to yourself (and others if you wish) to live your life every day in accordance with your values, you will find it much easier to face and conquer the fears which have become so debilitating and disabling.
In the final chapter, I will pull it all together, giving you step-by-step assistance in implementing this new way of living, along with some possible pitfalls, those things we therapists call “relapse prevention”. I will also explain what a typical session and course of treatment might look like for those of you who decide to seek assistance from a trained professional.
Body-Mind-Behavior Therapy and cognitive behavioral therapy are really very simple and straightforward, and all we as therapists do is teach you and coach you along until you know how to help yourself. If you listen intently, are motivated to change and face your fears, and work collaboratively with your therapist, you too can live a long, happy, and fulfilling life.
Finally, I will explain everything you ever wanted to know about psychotherapists, but were afraid to ask. Do you know the difference between a psychologist, a life coach, a licensed professional counselor, a spiritual healer, and a psychiatrist? Well, if you do not know, and are planning on seeking treatment at some point, it could be the most important information you ever learned. The differences are HUGE and the cost to you could be enormous, not only in terms of money thrown out the window, but in your emotional well-being as well.
Are you ready to start your journey from avoidance to acceptance? Well hold onto your seat, because here we go....
