For much of its history, Cognitive Behavior Therapy (CBT) has operated on the premise that changing maladaptive thoughts leads to a change in negative emotions. However, evolutions in the theory over time have shifted the focus of the model to address emotions and the question of emotion regulation more directly. These updates to the theory of CBT have significant implications for clinical practice, and arguably make the framework even more accessible to a wider variety of patients.
How CBT’s Approach to Emotion Has Changed
The more classical cognitive focus of CBT has its roots in the ABC model, one of the fundamental teaching tools in CBT since its inception in the 1950s. Originally developed by Albert Ellis, the ABC model theorises a causal, linear relationship between an Activating event (something that happens in the world, or an internal experience like a memory) which causes a Belief (the person’s thoughts or interpretation of that event), which in turn, creates a Consequence (the emotional and behavioral responses the person experiences). In other words, the model introduces the idea that it is our thoughts about our experiences, not the experiences themselves, that cause suffering.
Aaron Beck, the founder of CBT, adapted Ellis’ model to form the basis of his own cognitive theory. In Beck’s model, a linear relationship exists in which cognitions (or thoughts) cause emotions, and emotions then cause behavior and actions. By targeting a patients’ thinking first, and supporting them to cultivate an adaptive mindset, the cognitive therapist could help clients maintain a state of emotional equilibrium even in the face of difficult situations and circumstances.
In this video, Dr. David Tolin outlines a more contemporary CBT approach to emotion. Dr. Tolin has spent his career at the intersection of clinical practice and research into CBT, and as a celebrated clinical psychologist, author, and teacher, he has been at the forefront of CBT’s evolution over time. In this video, he points out that while historically CBT addressed emotions indirectly though the focus on cognitions and behaviors, modern CBT is more likely to address emotion regulation directly.
Contemporary CBT therapists have recognized over time that in practice, a bidirectional model more accurately accounts for clients’ experiences than Beck’s original linear one. Our thoughts can impact how we feel, and how we behave in response to certain circumstances, but emotions can also cause thoughts, and behavior can affect thoughts and emotions in turn. Rather than underlying cognitions being able to account for all emotions, and emotions to account for all behaviors, the relationship between these components actually runs in every direction simultaneously.
How Do Modern CBT Therapists Address Emotion Regulation?
This revision has significant consequences for the therapist in clinical practice. If the model is linear, the therapist's job is essentially one of correction: identifying the client’s distorted thought, challenging it, and replacing it. If the model is bidirectional however, the therapist needs to think more systemically, attending to the ways emotion, cognition, and behavior are continuously influencing each other, and intervening at multiple points in that loop rather than assuming a single entry point will be sufficient.
In CBT, the client’s presenting problem is formulated through understanding the interconnected emotions, cognitions and behaviors surrounding the issue. For example, if a client presents to therapy with social anxiety, a CBT therapist would investigate the client’s related cognitions (i.e. “I don’t belong”), emotions (i.e. shame and fear), and behaviors (i.e. declining invitations). In classical CBT, the therapist would typically approach emotion indirectly via a focus on cognitions or behaviors - in this example, that might involve pointing out how the client’s maladaptive cognitions about belonging are causing their fear of rejection. In more contemporary practice, therapists are more inclined to focus on feelings first, and to deliberately invite experiences of emotion into session as a means of facilitating emotion regulation, rather than only talking about them in a cerebral way.
How Does CBT Address Specific Emotions?
A contemporary CBT therapist might spend more time exploring the client’s experiences of fear and shame, and understanding not only the way in which these feelings are worsened by the client’s associated cognitions, but also the more complex interplay between the components of their anxiety. For example, the patient might identify that their shame increases after they turn down a social invitation, not only that the shame causes them to decline the invitation in the first place. The therapist might also pay special attention to moments where these feelings arise in session, and create opportunities where the client can contact the difficult emotion directly, practice tolerating it, and develop coping strategies in the context of a real felt experience. This is, in essence, the application of the behavioral strategy of exposure applied more broadly to emotional experiences. This approach has been used for a variety of disorders, but also issues like death anxiety, pathological jealousy, and phobias.
While CBT acknowledges that strong negative emotions can be problematic intrusions in a client’s life, the model is not anti-emotion altogether. Rather, CBT therapists support clients to find what Dr. Tolin calls the ‘sweet spot’ of emotion, where feelings can be acknowledged and recognised for their importance and usefulness, without overtaking the client’s life. As Dr. Tolin points out, it is usually strong emotions that lead clients to seek relief through therapy in the first place. Focusing more directly on the client’s feelings creates more opportunities for them to feel understood and to deepen the trust and rapport in the therapeutic relationship.
For therapists wanting to develop a more contemporary, emotionally-informed CBT practice, or for those wanting to familiarise themselves with the model for the first time, Dr. Tolin teaches Foundational CBT alongside Dr. Kevin Chapman and a faculty of other world experts in best-practice CBT.
