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How cognitive behavior therapy (CBT) can help reduce COVID-19 stress

By Dr. Sabrina A. Stutz, pediatric psychologist at CHOC Children’s

As the COVID-19 pandemic crisis and stay-at-home orders continue, many parents may notice changes in their own— or their child’s — mood, health habits, motivation and relationship with others. It can be stressful adjusting to this new experience and tolerating the uncertainty of this time. If you or a family member are experiencing significant mood or behavior changes related to COVID-19, cognitive behavior therapy (CBT) can help!

What is CBT?

CBT is a type of evidence-based treatment to reduce distress and unpleasant psychological symptoms. It is based on the idea that what we do is rooted in our thoughts, our feelings and our behaviors and that by changing them, we can improve our mood and wellbeing.

For example, if we get a good grade or performance report, we feel proud, we think “I can do this!” and we behave by sharing the good news with our family and friends. However, if someone bumps into or rushes past us, we might feel alarmed, we may think “How rude!” and we may respond with behaviors like shouting at them or complaining to someone, which makes us experience that cycle all over again.

For many of us, the thought-feeling-behavior cycle works on autopilot, and we simply react to the situation in front of us. However, when we identify and challenge unhelpful thought patterns and introduce healthier behaviors, we can change how we feel. CBT is designed to help us adjust our own thoughts, feelings and behaviors through mastering coping and problem-solving skills, in order to ultimately find a better sense of wellness.

How does it work?

CBT is a special type of talk-therapy provided by a trained mental health professional that is structured and time-limited, usually occurring for around 12-20 sessions. Sessions are spent on reviewing recent mood states and thoughts, learning and practicing coping skills, and problem-solving how to make these skills part of your daily life. CBT is highly focused on what is happening right now, and less focused on lengthy processing of your childhood or life history. Although your therapist may ask you questions about the past to get a better sense of what has contributed to your current thoughts, feelings and behaviors, most sessions will focus on what you can practically do about how you are thinking and feeling now, and how to create a brighter future.

CBT is the most rigorously researched type of psychotherapy, and studies have shown that it tends to work better and faster than other types of talk therapy to address a variety of psychological concerns. Many therapists consider CBT a gold-standard and first line of treatment. A variety of CBT approaches for specific populations have been found to be effective in reducing symptoms associated with depression, anxiety, post-traumatic stress, panic attacks, social anxiety, disordered eating, insomnia, headaches, psychosis, pain and more. Research shows that adaptations of CBT are effective for people of all ages including young children, school-aged youth, teens and adults.

What does it look like?

A CBT therapist can work with you to create a personalized CBT treatment plan and tailor it to your goals and lifestyle. Possible session topics may include, but are not limited to:

  • Emotion identification
  • Mind-body awareness
  • Mood/thought tracking
  • How the thought-feeling-behavior cycle affects you
  • Relaxation skills
  • Behavior activation (building in enjoyable activities and noticing your mood before/after)
  • Regulating strong emotions
  • Changing unhelpful thoughts
  • Challenging unhelpful beliefs
  • Problem-solving
  • Communication strategies
  • Identifying unhelpful thoughts or automatic thoughts

Below is a sample topic that is a staple of most CBT therapies — automatic thoughts.

Automatic thoughts

Thoughts are like the background music to our outward actions and attitudes. Automatic thoughts are like old songs that get stuck in our heads. They pop up unexpectedly, and we may not notice that the song is playing on loop, how it is affecting our mood, or even that we could be starting to hum some of it out loud. Automatic thoughts are instant, nonconscious, and often repeated thoughts to which our bodies and brains respond on autopilot based on our experiences and beliefs. We often don’t even notice that we are having an automatic thought unless we are paying specific attention to it, so we don’t assess whether or not it is a true or helpful thought. We don’t often challenge where we learned the belief behind the thought, whether that was a reputable source, or notice how it affects our mood or behavior. Rather, our minds sub-consciously accept the automatic thought at face value and act accordingly.

However, automatic negative thoughts (or ANTs) often pop up in our minds and cause distress or unhelpful behaviors. Automatic negative thoughts can be about yourself, someone else, or the future. Just like actual ants, automatic negative thoughts (ANTs) can arrive one after another, and soon our minds might be swarming with negative thoughts that can leave us feeling overwhelmed and stressed.

Common ANTs include:

  • I’m not good enough. (Or pretty enough, smart enough, _______ enough)
  • I’m a failure.
  • Nobody likes/loves me.
  • This will never end. I am going to feel this way forever.
  • What if _____ happens? (e.g., imagining the worst-case scenario)
  • I shouldn’t feel this way.

In CBT, a therapist can help you learn to identify these automatic negative thoughts when they are happening and take a closer look at whether they are accurate or helpful. Then, you can learn ways to change or adjust those thoughts when you notice them interrupting your mood and behaviors. Some CBT-based activities to change automatic negative thoughts might include:

  • Learning about common types or flavors of unhelpful thoughts
  • Finding evidence for and against a thought or belief
  • Increasing positive self-talk, as if you were talking to a best friend
  • Adjusting the language of your thought to be more realistic
  • Asking others what they think about it
  • Testing your “what if” theories

How do I get started?

Now more than ever, many therapists are offering sessions via telehealth. Research has shown that CBT delivered by telehealth can be just as effective as in person sessions. Contact your primary care provider, insurance company, or local mental health board for referrals to a local therapist. When you are choosing a therapist, be sure to ask whether they have had specific training in CBT and feel comfortable using it as a therapy model. CBT is best delivered weekly at first, in order to learn and practice skills, build momentum, and ensure an appropriate treatment plan to reduce symptoms as soon as possible.

While true CBT is done in consultation with a CBT-trained therapist, the principles underlying the approach can help anyone. If you are looking for self-help strategies, start by tracking your mood and thoughts. This can help you stay more in tune with your emotions and notice trends that affect your well-being. Then, build relaxation strategies into your schedule to help your body calm down and reduce unpleasant thoughts and behaviors. You can find other self-help CBT-based coping skills in these resources:

For kids

  • “Tiger-Tiger, Is It True? 4 Questions to Make You Smile Again” by Byron Katie
  • “How to Get Unstuck from the Negative Muck: A Kid’s Guide to Getting Rid of Negative Thinking” by Lake Sullivan, PhD
  • “CBT Workbook for Kids: 40+ Fun Exercises and Activities for Help Children Overcome Anxiety & Face Their Fears at Home, at School and Out in the World” by Heather Davidson, PsyD

For teens

  • Moodnotes —a teen-friendly app for tracking mood, thoughts and identifying negative thinking traps
  • Mindshift CBT — a CBT-based self-help app developed by Anxiety Canada
  • “The Relaxation and Stress Reduction Workbook for Teens: CBT Skills to Help You Deal with Worry and Anxiety” by Michael A. Tompkins et al.
  • “Conquer Negative Thinking for Teens: A Workbook to Break the Nine Thought Habits That Are Holding You Back” by Mary K. Alvord, PhD, and Anne McGrath,

For adults

  • Woebot — a CBT-based artificial intelligence self-care app designed by psychologists at Stanford University.
  • “Mind Over Mood: Change How You Feel by Changing the Way You Think” by Dennis Greenberger, PhD, et al. — a CBT-based self-help workbook for adults
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