Cognitive Behavioral Therapy (CBT)

Case Vignette

John was a 42 year old business executive who entered therapy due to an intense fear of public speaking. He had received several promotions over the years and had become a spokesperson on behalf of his company at a local, state and national level. He had just returned from the east coast where he had been scheduled to give a talk to potential investors, but at the last minute had suffered a severe anxiety attack that seemed much stronger than anything experienced in the past. He entered therapy out of concern that his anxiety in speaking publicly would affect his future chances for promotion.

The first set of skills John learned were deep relaxation techniques designed to assuage the physical symptoms of anxiety that he was experiencing, which included increased heart rate, sweating, nausea and trembling. He practiced the techniques several times a day, specifically when he was feeling good. If he could learn the techniques when feeling relaxed and stress-free there was more likelihood they would become second nature and be utilized when his anxiety kicked in. Immediate benefits that John noticed were an increased sense of control and improved concentration, and a decrease in his anticipatory symptoms.

While John was working on the relaxation training he also began to tackle the fearful thoughts that seemed to perpetuate his fear of public speaking. This negative self talk needed to be challenged and replaced with thoughts which were more realistic in nature and which increased his ability to cope. Examples of these thoughts included “I am going to make a fool out of myself, say something stupid, and people will make fun of me”; “everyone here is going to figure out that I’m just a fake and that I don’t know what I’m talking about” and “I’ll never work again if I can’t figure this out”. John kept a journal detailing these inner monologues and began to realize that certain cognitive distortions were contributing to his suffering including catastrophizing, overestimating and overgeneralization. We began to challenge the distortions with questions such as:

  • What evidence do you have for this thought?
  • Is this always true?
  • Has it been true in the past?
  • What is the likelihood of this taking place?
  • What is the worst possible thing that might transpire?
  • What would be so terrible about that?
  • What would you do if that occurred?
  • Are looking at the big picture?
  • Are you being objective?

At times John’s thoughts had a degree of truth to them and cognitive techniques designed to examine silent assumptions were incorporated. He recognized that throughout his life he had based his self-worth on his achievements, and believed that he had to be perfect in order to garner respect. These assumptions and mistaken beliefs were countered by similarly challenging questions that examined what John really wanted from his life.

Before he could tackle standing in front of large groups again, we began to expose him slowly but consistently to speaking situations in order to desensitize his anxiety. We accomplished this by examining the anxiety provoking situations and events that John was avoiding and then set goals to expose him to these situations while keeping a timeline to ensure his commitment. We began with using imagery where John visualized speaking in front of different groups of people beginning with family, friends, then colleagues, his boss and finally larger groups of people where he played a key role. He then developed an incremental hierarchy of real-life exposures, that ranged from speaking via the telephone and web-ex based conferences to those which had been a “10” out of “10” on his anxiety scale prior to treatment. After each exposure, both visual and actual, John fully processed his feelings and thoughts, gradually unlearning the connection between public speaking and his anxiety.

John continues to utilize cognitive behavioral therapy techniques prior to public speaking engagements, but he reports being much more focused and relaxed during such occasions and able to accomplish goals set. He has also spent some time reorganizing his priorities and is now happily married with a baby on the way! Conquering any fear can be a gut-wrenching experience but if you are committed to the process CBT is an invaluable tool.

For further information please explore the website of the Beck Institute for Cognitive Behavior Therapy.

Additional information