Using CBT to Change Your Behavior

Seth: And so an ongoing practice for me is reminding myself that it's all going to happen in real time, and I only ever have to do just this. I can just think like, do I have what I need to deal with what's happening right in this moment? And if I do, that's enough.

Brent: Welcome to Death Clock. I'm your host, Brent Franson. The mission of Death Clock is to help 100 million people live ten years longer. Today, we speak with Doctor Seth Gillihan about cognitive behavioral therapy. Doctor Gillihan is a licensed psychologist who is a full-time faculty member at the University of Pennsylvania, and now is primarily in private practice. He is the host of the Think Act Be podcast, and you can find him on Substack as well.

Brent: He's also the author of multiple books on cognitive behavioral therapy. So this is a really good topic where we go deep on understanding basically the relationship we have with our thoughts and how we can use the strategies that we learn about in cognitive behavioral therapy to help us exercise more or eat the right things to make changes to our lives that can help us be healthier.

Brent: He's a wonderful guest. It's his third time on the show. Hope you enjoy.

Brent: Doctor Seth Gillihan, welcome back to the show.

Seth: Thanks so much for having me back.

Brent: So you've been on a couple of times before, but it's been a year or two. It's been some time. So before we get into it, can you quickly remind us of your background and bio?

Seth: Sure. So I'm a clinical psychologist. Currently, mostly what I do is see patients as part of my outpatient psychotherapy practice. But before that, I taught psychology at Haverford College. And before that, I had a full-time, mostly research, somewhat clinical position at Penn. So I've transitioned gradually from a more research-academic focus to a more strictly clinical focus.

Brent: And do you just like seeing patients more? Is that where you get more out of that work?

Seth: I really do, yes. I could talk myself into thinking I was drawn to the academic stuff, and there are definitely aspects of that that I like. But really where my heart was and what drew me to mental health to begin with was just wanting to work individually with people and have that kind of relationship-focused work in the mental health world.

Brent: Awesome. We'll talk about cognitive behavioral therapy today. You've released a new book, Your Daily Reset: 366 Practical Exercises to Reduce Anxiety and Manage Stress Using Cognitive Behavioral Therapy. I'll give you an anecdote at the outset. In anticipation of this call, I was reviewing the book, and it's actually become part of our family's daily ritual in a way.

Brent: We've had a lot of authors on this podcast. I don't say this every time, so this is authentic. My nine-year-old daughter sometimes gets herself worked up about falling asleep. So we've really spent time thinking about what the ritual before bed should be. She's a quality time person and likes connecting.

Brent: And so what we do now is about half an hour to 45 minutes before she goes to sleep, we make some non-caffeinated tea. Then we sit around the little island in our kitchen and do one of your resets, and it has worked its way really nicely into the routine. This whole setup seems to work really well for my daughter.

Brent: We open it up to the current day, and we've done family members' birthdays and things like that. Then it's my wife, my daughter, and I, and we read through whatever the prompt is and chat about what it means for each of us. It's been awesome.

Brent: It's been really helpful. First, thank you. It's been fun and a cool way to get to know someone's work before chatting with them.

Seth: Brent, that makes me so happy to hear. Thank you for bringing that book into your family's daily life. I love that. Nothing makes me happier than knowing that the work I do might make a difference in someone's life, especially when it makes a difference in the life of a family. That really means a lot to me.

Brent: Yeah, and it's an easy way to use it. Whatever this combination of things is, it seems to be working. Maybe that will be the first question: as part of the strategy that's working to help my daughter transition into bedtime mode—and you know better than I do that insomnia is often the fear of not sleeping that keeps you awake—what is happening for her physiologically?

Brent: When we go through the exercise of using the CBT prompt to help her transition into bed, why would that be helpful for something like anxiety going to sleep?

Seth: Great question. I think the context in which you're using it is probably a big part of it, in that it is ritualized. There's that stabilizing effect of knowing that it's predictable. It's how we get babies to fall asleep to begin with, right? That's probably near and dear to your heart these days.

Seth: Establishing that routine and ritual so she knows it's coming, combined with the fact that it's something you and your wife do with your daughter, creates a human connection. That adds another layer of activating the parasympathetic nervous system, and oxytocin is probably getting released. As for the specific exercises, it depends on the day, but it's really interesting to me how big an effect just a little reminder can have.

Seth: That's why we called it "Your Daily Reset," because it's just that little moment of centering ourselves for a second and thinking: "What am I doing here? How do I really want to orient myself so I'm not just reacting and going on autopilot?"

Brent: I've found it really helpful. I thought we would do this because it'd be fun with you coming on the show, and my daughter could learn some CBT techniques while I refreshed my knowledge. But I find that even if you think you know it—and I probably have an overinflated sense of my own knowledge—it's still helpful.

Brent: It's a practice. It's not a binary of whether you know it or not; it's about reminding yourself of that practice. I've found it to be really helpful for myself, and my wife feels the same way. We hadn't expected that going in.

Seth: I definitely agree with that. It's much more about remembering than it is about knowing. If I asked you what tends to work, read an entry in the book, and then told you something that was the opposite, you'd recognize the correct approach immediately. But we just don't tend to keep these things top of mind.

Seth: Even for myself, having written the book, there are many days where I pick it up, wonder what today's practice is, and find it to be a good reminder for me too.

Brent: Can we start by reminding ourselves of the basics? What is cognitive behavioral therapy? Cognitive behavioral therapy can be a confusing phrase. It's used in therapy, but it isn't strictly limited to a therapy session. "Cognitive" is a bit abstract and not descriptive enough, so it can be a little misleading. We've all heard the term, but few of us could describe it simply.

Brent: So how do you describe what it is?

Seth: It sounds like something named by a psychologist, and we're somewhat famously bad at naming things. At its heart, it's a way of understanding how our thoughts, actions, and feelings are intimately connected. The things I think and the stories my mind tells me directly affect how I feel and what I do.

Seth: For example, if I come on your show and think, "I'm going to screw this up, sound stupid, or sound nervous," that will likely affect my delivery. Maybe I overcompensate by trying to sound overly authoritative and expert in a very stiff way.

Seth: Or I might get nervous and sweaty. Alternatively, we can tell ourselves better stories: "I know Brent, I like Brent, and we're just having a conversation. It's more about focusing on what's happening than trying to do a perfect job." Those small tweaks to what we tell ourselves can really affect how we feel and what we do. Similarly, the things we do have big effects on what we think and feel.

Seth: If I avoided going on podcasts altogether, I'd probably get more anxious and think I could never do it, feeling anxious every time I considered being on a show. But facing it, as we do in exposure therapy, causes that fear to diminish and helps our thoughts become more constructive. That's the heart of it.

Seth: We can we can talk more about some other aspects of it if it'd be helpful.

Brent: So the things we think and how we frame our thoughts impact our actions, and our actions frame how we think. You mentioned treating patients, and the word "therapy" is in cognitive behavioral therapy. Is there a school of therapeutic practice that is specifically CBT, where a therapist takes you through hour-long sessions each week focused strictly on a CBT approach, whereas other therapists do not?

Brent: Is it something that a therapist dips in and out of, or is it naturally present in everything? How do you think about the formality of it in the context of a traditional relationship with a therapist?

Seth: It's interesting, Brent. I came from a tradition that insisted: "We do CBT, CBT is what works." There are specific manualized programs for treating PTSD, depression, social anxiety, and so forth, with the belief that if you're not doing that, you're not doing effective therapy. Research shows that isn't true. While CBT has the most evidence in its favor among therapies, many other approaches also have strong evidence.

Seth: When you compare well-established therapies side by side, you don't typically see a greater benefit for CBT over other approaches, with a few exceptions like obsessive-compulsive disorder. But there are certainly practitioners—and I used to be one—who consider themselves strictly CBT therapists.

Seth: That felt like a box I was trying to fit myself into for a long time. Eventually, most of us recognize that the point of CBT is to be of service in therapy, rather than doing therapy in service of CBT. It's much more common for practitioners to use CBT as one tool delivered as necessary and appropriate.

Seth: It can certainly be helpful to have a focused approach where we work systematically on thoughts, behaviors, or both. I still do that at times, but more often now, it's interwoven with other approaches. This perspective might make hardcore CBT therapists cringe, but it's the reality of practice.

Seth: This is probably making them whatever. The equivalent of turning over in your grave is and you're still alive.

Brent: It's interesting to hear that from someone who has written several books specifically on CBT. The analogy that comes to mind for me is mixed martial arts. In mixed martial arts, the ultimate goal is to submit the competitor using whatever legal method works.

Brent: Brazilian jiu-jitsu has proven to be extremely effective for ground fighting, making it a dominant art form in MMA. But a fighter uses whatever discipline makes sense in the moment. If kickboxing is called for, you use kickboxing. You aren't there to serve Brazilian jiu-jitsu, even if it's your primary tool.

Brent: There seems to be a similar dynamic here. We aren't here to serve CBT; we are here to help people. CBT is often the primary tool we draw on, but if an interaction with a patient calls for a different framework, you draw on that instead. Does that analogy hold?

Brent: And maybe there's something similar here. It's okay. We're not here to serve CBT, we're here to help people. CBT probably is going to be what we draw on most. But you know, you mentioned exposure therapy or obsessive compulsive disorder okay. If the back and forth I'm in with the patient, you know, calls for me to draw on something that's not CBT, I should do that.

Brent: If that makes the most sense. Given the context, I don't know. Does that analogy hold?

Seth: Absolutely, I love that analogy. It might seem ironic that I'm being equivocal about CBT compared to other therapies, but the reason I focus on CBT in my writing for the public is that its interventions export so well into a self-administered format.

Seth: It's much harder to create a self-help book of 366 practices based on psychodynamic psychotherapy, where the treatment is fundamentally built around the live therapeutic relationship. In CBT, while the relationship matters for delivering the tools, it's ultimately about acquiring practical techniques to use in your daily life.

Brent: How do you think about the distinction between mental health and physical health? Having hosted around 100 conversations on this podcast, the first half focused heavily on mental health. As our focus transitioned, we began exploring physical health more deeply.

Brent: The more I've learned about both, the more I wonder whether drawing a sharp distinction between physical and mental health is actually helpful.

Brent: If you are physically healthy, you're likely to have better mental health, and vice versa. They are deeply intertwined. If someone is struggling with mental health, getting physical health habits dialed in seems like a logical first step.

Brent: There can be a slippery slope toward prescribing medication too quickly—treating symptoms rather than underlying causes. Setting aside severe conditions that strictly require immediate medication, for the average experience, do you think we've over-indexed on therapy while underestimating the impact of foundational habits like sleep, diet, and exercise?

Brent: But what do you think about that? Do you think we've over rotated on therapy and the need for therapy and under rotated on, hey, just you need to dial your sleep, diet and exercise and then let's see where you're at.

Seth: Assessing those fundamental cornerstones of well-being is a great place to begin therapy. We often ask new patients about sleep, diet, and exercise because research over the last decade or two shows increasingly strong evidence that physical health directly affects mental health.

Seth: The reverse is also true. Robert Sapolsky's book, "Why Zebras Don't Get Ulcers," offers an excellent discussion on the connection between psychological stress and physical health.

Seth: I've experienced this personally. When I had COVID, it temporarily affected my mental state. I found myself fixating on worries that I normally could let go of easily.

Seth: It was hard to move past them. Scientific studies continue to demonstrate that physical factors like viruses or bacteria can impact our psychological health alongside our physical health.

Brent: So you highlight that example to show how an exogenous physical factor, like a virus, can directly cause psychological symptoms that need to be understood in that specific context?

Seth: Yes, it's another piece of evidence showing how physical factors affect our nervous system. When we struggle with psychological health, it's helpful to consider potential physical components. If we focus entirely on trying to think differently or adjust our schedules while ignoring an underlying physical cause, it can be frustrating and lead to self-blame when we don't feel better.

Seth: But but when we're struggling with our psychological health, I think it's really helpful to consider at least the possibility that there may be a physical component to it, because if we're if we're focused only on like, I have to if I can just think about this in the right way or if I can just rearrange my my behaviors in a certain way or minimize my stress.

Brent: Consider two scenarios. Scenario A: Someone feels generally depressed recently and decides to see a therapist. Scenario B: Someone is going through a difficult divorce and decides to see a therapist.

Brent: In Scenario A, the best first step might be basic lifestyle adjustments: getting outside, moving, getting sunlight, avoiding alcohol, eating well, and sleeping early. Doing that for a few weeks might resolve the issue without needing therapy.

Brent: In Scenario B, the situation is acute and life-altering. Speaking from experience, going through a divorce is a time when therapy is immensely valuable for processing complex emotions and navigating major decisions with an objective expert.

Brent: And then in situation be. That's very situational. It's close for me. I went through a divorce and like that was the time when therapy was most helpful. I've done a lot of different types of therapy, but that was when it was myself. I was trying to figure out, wait, am I actually going to get divorced and trying to think through the whole decision?

Brent: Would you agree with that distinction, or is Scenario A an oversimplification?

Seth: I agree with that general distinction. I would also encourage foundational physical habits during acute crises like a divorce as a way to build resilience while navigating the hardship.

Seth: Patients have occasionally told me that their best therapy is something physical—like swimming, cycling, or running. I completely agree with them. Physical activities that make someone feel fully alive can be more effective than a conversation in an office.

Seth: The primary risk in Scenario A is if a therapist fails to look at lifestyle habits first and instead jumps straight into analyzing past trauma, taking a unnecessarily long path toward relief when direct lifestyle changes would have been more effective.

Brent: My mother is a therapist, so I respect the profession deeply. But over the last decade, culture may have over-indexed on the idea that therapy is the sole solution for every issue.

Brent: I should qualify my earlier point: therapy or medical intervention can sometimes cause harm. As a teenager, I was misdiagnosed and prescribed heavy medications that took years to taper off of, particularly affecting my sleep.

Brent: There can be downsides when interventions are applied inappropriately. While therapy and medication have their place, basic physical habits are frequently overlooked.

Brent: Additionally, open-ended therapy that continues weekly for years without specific goals isn't always optimal. Poorly executed therapy can overemphasize negative experiences in a way that proves counterproductive. What are your thoughts on those critiques?

Brent: So I don't know, what do you think as somebody who, you know, you spend your career practicing, that's what you love to do. That's what you're passionate about doing. What do you think about those criticisms?

Seth: Those critiques are fair and can apply to CBT as well. However, one strength of CBT is its emphasis on being time-limited and practical. Patients have joked that I'm the only therapist who actively tries to fire himself, but the goal is to empower people to manage independently.

Seth: CBT research frequently incorporates behavioral interventions like exercise. The goal isn't to force patients into a rigid theoretical framework or insist that every past issue must be fully resolved in session for progress to occur.

Seth: Starting with foundational habits offers a practical path toward quick improvement. That philosophy underpins "Your Daily Reset": offering simple strategies that help you get out of your head and focus on actions that improve well-being.

Brent: At its core, CBT fosters a healthier relationship with our thoughts. We often give unhelpful thoughts far more power than they deserve—an evolutionary default that kept ancestors alive in dangerous environments, but less helpful in modern life.

Brent: Reminding ourselves to evaluate thoughts objectively is essential, and your book outlines those strategies clearly.

Brent: A good therapist periodically evaluates whether a client is ready for a break or step-down in care, rather than continuing indefinitely without reviewing progress.

Brent: To play devil's advocate against a purely "lifestyle-first" view: building good habits is difficult. Starting a daily exercise routine or changing dietary habits requires mental effort.

Brent: Understanding cognitive behavioral strategies makes it easier to adopt sustainable habits like regular exercise or eating better.

Brent: How does CBT help us implement basic health habits when making those changes feels challenging?

Seth: CBT plays a key role here because the main obstacles are often cognitive or behavioral. We might hold unhelpful assumptions or try to change habits too quickly—like attempting an intense running routine when we dislike running.

Seth: CBT helps identify flexible ways to achieve desired goals. Unlike a quick doctor's visit where you are simply told to exercise, therapy works through the actual process of making that change manageable.

Seth: If simply knowing what to do were enough, most people would execute it easily. But inertia and overwhelm often interfere.

Seth: Therapy helps break daunting tasks into manageable steps, acting like a ladder to span the gap between where you are and where you want to be.

Brent: It's an interesting dynamic: a mental health professional may sometimes be better equipped to support preventive health than a primary care physician, who primarily handles acute issues, prescriptions, and screenings during short appointments.

Brent: Mental health practitioners can help clients build the behavioral habits required for long-term prevention.

Seth: It's a useful perspective. Occasionally, patients with unexplained physical symptoms are told by medical specialists that the cause must be psychological. Yet sometimes a mental health professional recognizes that a physical condition, like Lyme disease, was overlooked.

Brent: That may be a function of session length. A mental health professional typically spends 45 to 50 minutes listening closely, whereas standard medical appointments are brief.

Brent: Let's apply CBT to a practical example. I often experience strong cravings for a drink in the hour or two before dinner. Once I eat, the craving disappears. While I rarely have more than two or three drinks, even that amount impacts my sleep quality and patience.

Brent: During that pre-dinner window, it feels difficult to resist despite knowing I'd prefer not to drink.

Brent: Is there a CBT strategy to employ around 4:00 PM to manage that impulse and reach dinner without having those drinks?

Brent: Like, what am I telling myself in my brain to help me win the battle and make it to dinner without the 2 or 3 beers?

Seth: Three approaches come to mind. First, environmental and behavioral adjustments: make the unwanted behavior harder and the desired behavior easier. If alcohol is easily accessible, avoiding it requires continuous willpower.

Seth: We encourage making one clear decision in advance to eliminate repeated choices later. A helpful metaphor comes from Homer's Odyssey, where Odysseus had his crew tie him to the mast so he couldn't steer toward the sirens when his resolve was low.

Seth: Setting guardrails when willpower is high prevents reliance on willpower when energy is low.

Seth: So I can I can pause there, or we can we can plow ahead.

Brent: I try setting clear rules, like substituting a non-alcoholic beer. Since eating eliminates the craving immediately, removing physical triggers helps.

Brent: What does CBT recommend for handling days when you don't stick to the plan? Is self-compassion or strict accountability more effective afterwards?

Brent: That is the okay, I've failed. I had the couple of beers, and now I'm just like, next time I hope to win that bottle. Is there, a compassionate talk track that's on the other end of that? Is there a beat yourself up a lot talk track that's on the other end of that? Like, what's your recommendation on the days when you lose the battle and you have the beer, you have the dessert?

Brent: I mean, we can all think of an example of this for ourselves.

Seth: Self-compassion is far more effective than self-criticism. Struggling with habit change is a common human experience, not a personal flaw. From there, we conduct a functional analysis to examine what drives the behavior: the antecedents, the immediate desire, and the long-term consequences.

Seth: For example, if blood sugar drops around 4:00 PM, the brain seeks quick energy. Having a light snack or fruit at that time can address the physiological trigger directly.

Seth: Self-criticism often prolongs unhelpful habits by creating negative feelings that tempt us to seek quick relief.

Seth: So yeah, but that's that's it, as I'm sure you know, that that's the cycle of of, of substance abuse often follows or will say unhelpful substance use often follows that pattern where we try to resist, we don't. We beat ourselves up, we feel even worse. And then that just leads to more of the same type of behavior.

Seth: One, because we feel bad about ourselves, maybe we're trying to numb that, but also then we haven't really focused on how can I fix this in the future?

Brent: It raises the question of perfectionism versus self-compassion. If giving in to a craving happens only once or twice a month with moderate intake, is perfectionism creating unnecessary concern?

Brent: Having experienced hyper-addictive cycles in the past, I know what extreme dependence looks like. Now, while I think about having a drink most late afternoons, I rarely give in, and intake remains modest when I do.

Brent: How do you evaluate perfectionism when high standards come from a reasonable desire for better health and sleep?

Brent: And my wife's like, dude, get a couple beers, just relax. Like, you know, it's tomorrow's a new day. But I know that I'm like, yeah, but I kind of think about it every day. There's something not right about that. I wish I only thought about it twice a month when I lost the battle. And so how do you think about perfection is, because it's rooted in a good place.

Brent: Somebody is like, I don't want to ever have dessert or, you know, sugar is not good for you. I don't want to ever have those drinks. And it screws up my sleep versus like, hey, we're human beings. Like, I don't know, maybe, maybe a couple beers twice a month isn't the end of the world.

Seth: While moderation works for many, some individuals perform better with clear, definitive rules rather than negotiating each decision.

Seth: Adopting a firm boundary—similar to a clear dietary choice—eliminates decision fatigue, making it easier to maintain consistency.

Seth: Like, I just don't do that. So I have to decide every time. It's not. Not so painful. And it's easier to make that decision definitive if you're not kind of partially in a sugar addicted state. So your body's kind of counting on it.

Brent: There's an old recovery phrase: "One is too many and a thousand is never enough."

Seth: Yeah.

Brent: If that resonates for a particular habit, moderation might be harder than a simple rule. Eliminating daily debate simplifies the decision process.

Brent: One of the most powerful mindset shifts for health and personal goals is overcoming the internal narrative of "I don't feel like it."

Brent: That single thought derail many healthy intentions and long-term plans. Moving past it consistently enables major progress.

Brent: What does CBT teach us about pushing past hesitation to execute planned actions, whether running, eating well, or showing up for commitments?

Brent: I'm going to eat the salad. I know I need to show up for the appointment. There's a thousand different ways this can manifest, but what can we learn from CBT on that?

Seth: The thought "I don't feel like it" often stems from an underlying assumption that we should only act when motivated. Relying on immediate mood is rarely a reliable strategy for long-term health or responsibilities.

Seth: A common misconception is believing motivation will spontaneously appear in the future. Recognizing this thought pattern helps us decouple action from momentary feelings.

Seth: Like that's obviously not a good basis for your your sexual morality. But even in terms of things like, like, do I feel like emptying the dehumidifier like, well, I mean, probably like a thousand times out of a thousand. No. And it needs to get emptied. But I think an even more pernicious story behind that question is I will do it when I feel like it, but when am I going to feel like doing it?

Seth: Avoiding tasks reinforces avoidance because relief provides temporary positive feedback, reinforcing the cycle of delay.

Seth: It wants to repeat the behavior that led to that feeling.

Brent: Where do you find these challenges arising in your own life? Despite your expertise in CBT, what personal habits or tendencies still require ongoing attention?

Brent: Right. And it's, you know, it's it's about continuing the battle to make the changes you want to make. And it's not like there's some destination where you've won and everything's perfect.

Seth: Yeah. No, that's that's that's definitely that's definitely the case. There's no end point for any of us in this lifetime. But I, I want to make sure I'm answering the question that you're asking. So what? What is it?

Brent: Even with extensive knowledge of strategies, where do you personally notice resistance or hesitation?

Brent: I know all the strategies, but I still I don't, you know, my dehumidifier tank is never emptied.

Seth: For me, it's worry. Even knowing it's unproductive, I still experience anticipation and morning stress about managing the day ahead.

Seth: My mind tends to stack all upcoming appointments and family responsibilities together at once, creating a feeling of overwhelm.

Seth: I've got this many, like therapy appointments and then I've got to do that with the kids. And and so I find myself doing what, what I but I think of is as taking a whole day's work and with which plays out moment by moment. Only one thing happens at a time, but my brain will turn that 90 degrees.

Seth: My practice is reminding myself that events unfold sequentially in real time. Focusing exclusively on the present task keeps workload manageable.

Seth: Asking simply "Do I have what I need for this exact moment?" brings focus back to present resources rather than projected demands.

Seth: Staying grounded in the present moment ensures we remain within our current capacity to handle challenges.

Seth: So that's that's where I, that's that's probably a project of a lifetime to, to keep coming back to, to just this.

Brent: Focusing on one step at a time is key. Where can listeners find your book, podcast, and updates?

Brent: Where can we? You know, where can we find the book? I'm assuming it's just Amazon, but tell us a little bit about where we can find more info on on you and on your work.

Seth: Substack is the best place to find my newsletter and the Think Act Be podcast. After a busy period of creating books and courses, I'm currently taking a rest period to recharge before starting new projects.

Seth: So I feel like I'm in maybe a kind of creative winter and some things are sort of stirring, but but, I'm kind of interested to let them, let them kind of, do their thing. I'll. I'll see what emerges eventually. When, when spring time comes.

Brent: Doctor Seth Gillihan, thank you so much for joining us.

Seth: Thank you so much, Brent. Great to see you.

Brent: Death Clock is recorded in Boulder, Colorado, and San Francisco, California. Produced by Patrick Gudino, music by Patrick Lee, and hosted by Brent Franson, founder and CEO of Death Clock.