What is emotionally focused therapy (EFT) for couples?
Cognitive-behavioral therapy (CBT) is considered one of the most evidence-based and widely disseminated therapeutic approaches. A 2012 review of meta-analyses found CBT helpful for many forms of psychological suffering, including anxiety, depression, insomnia, chronic pain, addiction, anger, and eating disorders.
One of the core CBT interventions is helping clients identify and change cognitive distortions. Also called “thinking errors” or “thinking biases,” cognitive distortions are ways of thinking that don’t accurately reflect reality and greatly contribute to psychological distress.
How do you start using CBT techniques for cognitive distortions?
Providing psychoeducation to clients is the first step in using CBT techniques for cognitive distortions. This involves teaching clients what cognitive distortions are and how to identify them in their own thinking styles.
Usually, the first homework assignments in CBT for cognitive distortions involve having clients complete a CBT thought record worksheet to begin to track their thoughts in real time. Typically, clients are only asked to track negative thoughts associated with the treatment goals and diagnosis.
Once the client has accumulated several relevant examples of negative thoughts, it's helpful to review the list of the common cognitive distortions and help clients identify which distortions they connect with.
What should you keep in mind before starting treatment?
Clients’ symptoms may worsen if they track their thoughts but continue to believe those thoughts are true and accurate. Make sure clients understand that thoughts are not facts and that the point of tracking them is to begin to challenge them.
Also, keep in mind that this is a collaborative process, and avoid telling clients they have particular distortions. When walking through the list of cognitive distortions with your clients, make sure to take a compassionate and curious attitude, and always allow the client to take the lead.
Finally, when using CBT techniques for cognitive distortions, try to show and not tell your clients. It can seem alluring to explain to your clients exactly how their thoughts are distorted, but these CBT interventions will be infinitely more helpful if they can get to this realization themselves.
List of cognitive distortions and associated CBT interventions
For the rest of this article, I’ll explain some of my favorite ways to help clients work through each of the thinking distortions using reframing exercises and Socratic questioning methods in CBT. I won’t be fully defining the distortions in this article, but you can refer to the list of cognitive distortions with definitions.
This list of cognitive distortions includes common thinking patterns that therapists can help clients identify and challenge using CBT. CBT techniques for cognitive distortions can help clients recognize unhelpful thought patterns, evaluate the evidence behind their thoughts, and develop more balanced interpretations.
Black-and-white thinking
Teaching clients how to “find the gray” for the black-and-white thinking cognitive distortion can be immensely helpful. The “gray” refers to the middle ground between two extremes of thinking that often come with anxiety or depression.
For example, imagine a client tracked the thought, “If I’m not successful, I’m a failure.” Finding the gray in this instance might involve helping the client realize, “Sometimes I succeed, and sometimes I fail. Outcomes do not define me.”
Catastrophizing
This is one of my favorite distortions to work with on the list of cognitive distortions. My go-to CBT intervention for this cognitive distortion is called “de-catastrophizing” and involves walking clients through four simple questions:
What is the worst-case scenario?
What is the best-case scenario?
What's the most likely scenario?
If the worst case happens, how will you cope with it?
Labeling
One of the CBT techniques for cognitive distortions therapists can use is helping clients replace global labels with specific, observable descriptions. Labeling (the self or others) involves overattaching to broad, arbitrary categories that imbue unhelpful extra meaning. Helping clients move from labels to descriptions can enable clients to develop more accurate and helpful thinking patterns.
For example, if a client with body dysmorphic disorder has the thought, “The scar on my face is hideous,” you can walk them through noticing the factual physical details of their face while withholding judgment. A description might sound like this: “There is a scar on my right cheek. It’s about the size of a pea. It’s white and shaped like a ‘z.’”
Emotional reasoning
Cognitive reframing exercises can help clients evaluate the evidence behind emotion-driven thoughts and develop more balanced interpretations of their emotional experiences. Simply helping clients step back and mindfully notice when emotional reasoning is present (e.g., when they're mistaking feelings for facts) can help ground them in reality instead of getting caught up in a torrent of distressing feelings.
For example, a client with panic disorder might think, "It feels like I’m going to go crazy, so I probably will." You can have them acknowledge that this is a very common thinking distortion, and while it feels true, it’s actually a symptom of the disorder. They can then re-affirm to themselves that there’s no data indicating a danger, and then shift their attention back to what is happening in the moment.
Shoulding
Other CBT techniques for cognitive distortions include helping clients examine rigid expectations, identify the values behind their goals, and develop more flexible, realistic self-talk.
Shoulds and musts are arbitrary rules often dictated by clients' own past experiences and societal rules. Helping clients differentiate whether the “should rule” is guided by their own intrinsic values or external arbitrary narratives can help them respond in ways that are more authentic and empowering.
For example, if a client is having the thought, "I should go to the gym three hours every day," you might help them see that this ‘should’ is driven by an inner critical voice and not by the kind of person they want to be.
Mental filtering
When clients are falling into the mental filtering trap, mindfulness exercises can help them expand their awareness and notice other elements of a situation that their anxious or depressed brain isn't letting them attune to.
For example, a client with depression might think, "I didn't do anything today. I was in bed all day and on my phone.” This thought itself would be quite depressogenic. As part of a behavioral activation treatment, you might first help them identify the positive things that they are already doing. For example, they may not realize that they have been taking small but important steps to recovery, such as making themselves a snack, getting a cup of coffee, or walking to the mailbox.
Mind reading
Challenging the mind reading distortion (which is a major component of social anxiety) can be done by having clients shift their perspective and asking them what they would think if they were in the other person's shoes. Alternatively, you can help clients consider alternative explanations for what the other person might be thinking.
For example, if a client working on anger management is triggered because he feels like somebody at a party was staring at him in a negative way, you might help the client consider other, non-hostile intentions of the person, such as that individual might be attracted to him or that individual might be neurodivergent and not understand eye contact or staring.
Alternatively, you can use Socratic questioning in CBT to help clients examine the evidence for their assumptions and consider alternative explanations for what the other person might be thinking.
Fortune telling
CBT techniques for cognitive distortions such as fortune telling can include reviewing past predictions, examining evidence, and estimating how likely a feared outcome is to occur.
To help clients with fortune telling, you can explore past instances where the client had predicted something would happen, and discuss with them how often their predictions were accurate vs. inaccurate.
Once clients understand how faulty fortune telling tends to be, you can then help them keep their attention in the present moment using mindfulness of the breath and mindfulness of the senses.
Remember, even if the fortune telling is correct and a negative event happens, you can help your client discover that dwelling on it in the moment is likely unhelpful and creates extra suffering.
Conclusion
CBT techniques for cognitive distortions offer simple, quick, and powerful ways to help clients change the relationship they have with their thoughts by thinking more accurately and pragmatically, while giving them the ability to take perspective in flexible ways.
Sources
Beck, J. S. (2020). Cognitive behavior therapy: Basics and beyond. Guilford Publications.
Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive therapy and research.
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