Recognizing the automatic elements — the habit patterns you have
Many people have heard of "CBT" — Cognitive Behavior Therapy. The method has roots in the behaviorist theories and research of Ivan Pavlov, Thorndike, Watson, and Skinner, put into clinical practice by Edmund Jacobson, Joseph Wolpe, and others, and later extended by the cognitive theories of Albert Ellis, Aaron Beck, Carl Thoresen, and many others.
The first wave of non-psychoanalytic therapies was behaviorism. The central idea is that you can change your automatic reactions to events by applying straightforward principles. If you are afraid of getting into a swimming pool, you learn to relax deeply and imagine looking at a pool from a distance — then sitting closer, then sitting on the edge, then getting your feet wet. You practice small versions of this in real life. This is exposure therapy, sometimes called counter-conditioning. It works.
The second wave emphasized the role of thoughts — cognition — in shaping behavior and feeling. Cognitive therapists demonstrated that your interpretation of a situation heavily determines how you feel about it. If someone cuts you off on the highway and you avoid a collision, you might think furious thoughts about the other driver — and feel angry, and drive less well as a result. If instead you congratulate yourself for being alert and skillful enough to avoid a nasty accident, you will feel something quite different, and drive better for it. That is cognitive therapy in a sentence.
The third wave brought mindfulness and acceptance to the foreground — practices with deep roots in contemplative traditions, particularly Buddhism, integrated into rigorous clinical frameworks such as Mindfulness-Based Stress Reduction, Acceptance and Commitment Therapy, and Dialectical Behavior Therapy. These approaches have substantial empirical support. What they share is an emphasis on observing your inner experience with clarity and without automatic reactivity — creating a moment of space between event and response. That space is genuinely useful. My own view is that what you choose to do with that space matters enormously, and that is where CBET picks up the thread.
Cognitive Behavior Therapy, broadly understood, encompasses all of these waves. After all, deciding to simply observe your thoughts and feelings is itself a cognition. The various branded approaches — MBSR, ACT, DBT, and others — can all be understood as particular configurations of the same underlying CBT logic.
The problem I see in the current state of the art is that feelings — the emotions — are typically treated as if they were inevitable, automatic reactions to situations, perhaps modified by thoughts or behaviors, but inherently fixed "facts." I was taught that explicitly early in my training: feelings are facts. I have had many patients marvel at the freedom they experienced when I introduced them to a different idea: that feelings, like thoughts, like behaviors, are not fixed facts at all — that we can actually choose, in advance of a situation, how we would like to feel, think, and act when that situation arises again. This is possible because we have powerful capacities for imagining situations not only from the past but into the future.
To the lay reader and to the professional who may read this, I offer the term Cognitive Behavior Emotion Therapy — CBET. The diagram below illustrates what I mean. Events occur in a continuous stream in everyone's life. Each event triggers highly automatic patterns of thoughts, feelings, and behaviors — a "molecule" of habit, with double-headed arrows between each element because the three mutually cause each other. Events can trigger behaviors, feelings, or thoughts in any order. Sometimes something happens and you break into a smile before you've consciously registered why. The pattern runs as a whole, largely below awareness. The first step in CBET is simply to recognize that this automatic pattern exists — and to ask honestly: is it working for you?
Altering the future version of you
These patterns are learned over a lifetime, beginning in childhood — by observing others' responses, and by having your own reactions rewarded or not. The question that matters is whether these automatic, habitual patterns work for you. In biology we use the terms adaptive and maladaptive, and I use them in a specific sense here. Adaptive means a pattern that helps you fit in with and prosper in the world you actually live in. Maladaptive — malo meaning bad — means a pattern that doesn't help, or actively hurts you. Repeatedly.
CBET seeks to:
- Help you identify your automatic reactions to situations — the habitual thought-feeling-behavior pattern that runs when a particular kind of event occurs
- Identify the events and triggers that set off this reaction
- Accept that these events are very likely to happen again — the careless driver will reappear; the difficult colleague will say that thing again
- Decide how you would prefer to feel the next time such a thing happens
- Design the thoughts and behaviors that would support the feeling-state you want to have — because in the new pattern, feeling leads and the other two follow
- Practice first in your imagination, vividly and in detail, and later in small real-world versions of the situation
- Smile at yourself, knowing that you are constructively altering your future self
It is critical to understand that even if this plan — or the diagram — makes complete sense to you, understanding these ideas will do very little to change your future behavior on its own. What changes your future behavior is practicing a new pattern. Repeatedly. Until you begin to see it emerge naturally in real situations. When that happens, you will know that you didn't just read this page — you understood it.
There is no neurofeedback without CBET
Arnold Lazarus, one of the most rigorous and creative clinicians of the twentieth century, proposed that a complete account of a person's psychological life requires attending to seven dimensions simultaneously: Behavior, Affect, Sensation, Imagery, Cognition, Interpersonal relationships, and Drugs/biology — the BASIC ID. He called this multimodal therapy. It remains one of the most comprehensive frameworks ever offered for understanding what a human being actually is and what can go wrong, and right, in a life.
Everything we do at Behavioral Medicine Associates operates within that framework — and within the CBET framework that encompasses it. There is no clean boundary between neurofeedback, biofeedback, and talk therapy. When a patient learns to stabilize a heart rate coherence graph, they are doing operant conditioning — yes. But they are also forming an image of the graph moving the way they want it to move, generating a feeling-state that supports the physiological shift, noticing their self-talk, and building a metacognitive skill: the knowledge that they can influence what they once believed was beyond their control. That is CBET working through a physiological channel.
A clinician might say to a patient watching a coherence graph: "You'll surprise yourself at how long you can stabilize that graph — when all you did was imagine it floating steadily." That sentence is simultaneously Ericksonian suggestion, cognitive reframe, imagery rehearsal, and operant reinforcement. The modalities do not separate cleanly in practice. They never did.
What we offer is not a menu of techniques. It is a unified understanding of how organisms — minds and bodies together — learn, get stuck, and change. The tools vary. The framework is one.