Cognitive Behavioral Therapy (CBT)

This article provides a comprehensive overview of cognitive behavioral therapy, including the main features, how it works, why it’s effective, and what to expect during treatment.

Key Takeaways:

• Cognitive behavioral therapy is the most common form of psychotherapy. It has decades of research behind it showing benefits for a wide range of mental health conditions and other concerns.

• The key focus of cognitive behavioral therapy is identifying and addressing dysfunctional thoughts and behaviors. The goal is to change these into more positive, adaptive ones that reduce distress and promote better function and well-being.

• Cognitive behavioral therapy requires multiple sessions, as well as commitment and motivation from the patient. It is not a quick fix, but it often leads to significant and long-lasting changes for many individuals.

Understanding Cognitive Behavioral Therapy

Cognitive behavioral therapy (or CBT) is a specific form of psychotherapy that focuses on dysfunctional thought patterns and maladaptive behaviors that contribute to distress and poor psychological health. It is based on the belief that your thoughts, emotions, and behaviors can all influence each other. ^[1]

Therefore, CBT was essentially developed as a way to change dysfunctional thoughts and behaviors into healthier, more adaptive ones, so that the individual experiences less distress and can function better in everyday life. It is also designed to promote greater stress management, self-esteem, and resilience, among other positive psychological traits. ^[1]

Why CBT is so Widely Used

CBT is the most widely used form of psychotherapy. This is mainly because it is the most well-researched and backed by hundreds of quality research studies showing its effectiveness. In addition, no other form of psychotherapy is more effective across a wide range of mental health disorders and concerns. ^[3]

Conditions Commonly Treated with CBT

CBT is used for many different psychiatric conditions, including: ^{[1] [2] [4] [5]}

• Anxiety.

• Depression.

• Post-traumatic stress disorder (PTSD).

• Social anxiety.

• Alcohol and substance use disorders.

• Attention-deficit hyperactivity disorder (ADHD).

• Phobias.

• Obsessive-compulsive disorder (OCD).

• Personality disorders.

• Eating disorders

CBT has also been shown to be effective for other concerns too, such as: ^{[2] [4] [5]}

• Insomnia.

• Chronic pain.

• Chronic fatigue.

• Migraines

• Irritable bowel syndrome (IBS).

• Low self-esteem.

How it Works

Cognitive behavioral therapy primarily works by promoting healthier, more adaptive thoughts (or cognitions) and behaviors. CBT focuses specifically on one’s present issues and how to correct them, rather than focusing on past events (although these are important in certain situations too, especially in cases of trauma). ^{[2] [6]}

CBT is based significantly on the cognitive model of mental illness, which highlights three levels that can contribute to distress: ^{[1] [2]}

• Core beliefs: deeply held beliefs about oneself, others, and the world

• Dysfunctional assumptions: rigid rules for living, which are often irrational or unrealistic

• Negative automatic thoughts: automatic responses one has to certain events or circumstances

The other part of CBT is addressing maladaptive behaviors. Examples of maladaptive behaviors include anxious avoidance, procrastination, self-harm, or aggression, but many possible ones are depending on the exact situation.

Essentially, the therapist works with you to help identify your current thoughts and behaviors, and then uses specific techniques to challenge these and adopt healthier alternatives. The relationship between therapist and patient is meant to be a sort of partnership, with support, non-judgment, and encouragement. ^{[2] [4]}

Listed below are specific techniques commonly used in CBT sessions: ^{[2] [7]}

Cognitive

• Thought records: to identify negative automatic thoughts, distinguish thoughts from facts, and see how thoughts influence moods.

• Guided discovery: to become aware of underlying assumptions and explore alternative perspectives and solutions.

• Evidence listing: to see if assumptions actually have evidence and are true or not.

• Problem-solving skill development: to cope with difficult situations.

• Developing self-confidence.

Behavioral

• Activity scheduling: to plan each day and reduce decision fatigue.

• Graded/progressive task assignment: to help someone progress their behaviors in small, manageable steps without causing overwhelm.

• Behavioral experiments: to allow one to test out their negative or catastrophic predictions. Particularly used for anxiety disorders, using hierarchical tasks from the least anxiety-provoking to the most anxiety-provoking.

• Progressive relaxation/breathing exercise: to reduce stress and arousal.

• Role-playing: to help prepare for anxious or stressful situations.

• Mind/body relaxation exercises.

Examples of CBT

Each CBT session will be different depending on the individual’s symptoms, goals, and other factors. However, there are common examples that can help illustrate the nature of CBT.

For example, if someone has depression, the therapist can help work with the patient to identify negative thoughts, such as “I’m worthless” “everything is bad”, as well as dysfunctional behaviors, such as procrastination or disengagement from previously enjoyed activities.

They will then use techniques to help the individual adapt more rational thoughts, recognize some of their strengths and positive characteristics, and also implement graded behavior progressions to help the individual achieve feelings of accomplishment and to engage in activities of interest.

As another example, take someone with social anxiety. He or she may have severe, irrational fears of judgment from others, as well as negative thoughts and beliefs about oneself, such as “I’m awkward and weird” or “I always mess up”.

CBT in this case would be centered around correcting those thoughts and improving self-confidence and self-esteem. The therapist may also implement exposure therapy or other behavioral experiments to gradually get the person to face their fears, so they can gain more confidence and reduce anxiety in the future.

What to Expect from a CBT Session

In the first one or two sessions, your therapist will make sure that you’re comfortable with this therapy and that it’s a good fit for your situation. They’ll ask questions about your life and background, current issues, and goals for treatment. Then, an action plan is formed, which can be modified later on depending on progress, adherence, and overall fit for you individually. ^{[1] [6]}

After this, the most productive work begins. You and your therapist work together to identify how your thoughts, feelings, behaviors are interacting with each other and affecting your mental well-being. Very often, questionnaires and worksheets are implemented to identify and work on your specific issues. You also may be given “homework”, or specific exercises to complete in daily life outside of these sessions. ^{[4] [6]}

Development and Progression

At each session, your therapist first checks in with your current mood and mental state. The exercises or other relevant information from past sessions are reviewed and discussed, and then an agenda is collaboratively planned for the current session. ^[1]

Progress can be marked in several ways, such as self-monitoring of your thoughts and behaviors, or through clinical measures. Once positive changes are being made, the therapist may also work with you on specific strategies for relapse prevention and long-term maintenance of positive thoughts and behaviors. ^[1]

How Long Does it Take?

The duration of CBT can vary greatly from person to person. It’s influenced by symptom severity, the specific problems, and the effectiveness of the sessions.

In general, CBT typically lasts at least 6 weeks and may go up to 6 months or longer. Most people end up going to CBT for 12 to 20 weeks, having between 6 to 20 total sessions, with each session lasting 30 to 60 minutes. ^{[4] [6]}

Preparing for Your First Session

Before your first session, you may feel a mix of emotions and different thoughts. You may be hesitant, anxious, excited, or motivated.

To help prepare for your session, it’s helpful to identify and write down your main issues, overall goals, and any questions you have for the therapist. The more honest and open you are, the more they can help you.

Goals and Expectations of CBT

The main goal of CBT is to help address any dysfunctional thoughts or behaviors that are negatively impacting your life, so that you can feel mentally well, cope better with stress, and function better overall. Essentially, you learn to be your own therapist because you are ultimately the one who learns how to change your thoughts, behaviors, and emotions, and how to continue these positive changes. ^{[1] [2]}

CBT also often has a significant long-term impact, even after you finish the treatment. Research shows that many individuals experience positive effects for up to a year or longer after treatment, and that CBT can help prevent relapse. ^[2]

CBT is not a direct cure, nor is it a quick fix. It requires a long-term commitment, but it is a highly effective treatment for a wide range of psychological issues and other problems if you stick with it. Sometimes, CBT may be all that you need to feel better, but it is also used alongside medication or other treatments in certain cases, especially with more severe symptoms. ^{[1] [2] [4] [6]}

Finding a CBT Therapist

There are many CBT therapists available, but finding one that is a great fit for you personally can sometimes be stressful or time-consuming. Fortunately, there are ways to help speed up this process, so you can narrow it down to one or a few possible therapists.

For example, your primary care doctor can recommend certain therapists based on your unique goals and circumstances. It can also be helpful to speak with family, friends, or others you trust who have had positive experiences with therapists. There are also many online search databases where you can search for therapists based on specialty, location, qualifications, and other relevant information. ^[4]

Getting the Most Out of CBT

CBT is often effective, but it does take time and effort. Here are some tips to get the most out of CBT:

• Be open and honest: It can be hard to open up, especially at first. But the more you do, the more specific and individualized the treatment can be.

• Set clear, actionable goals: You and your therapist should achieve mutual agreement on what to work on and how to achieve your goals.

• Be consistent, even on days when you don’t feel like it.

• Remember that it takes time; there are no quick fixes.

• Maintain motivation by celebrating small “wins” and progress.

• Complete any exercises or “homework” assigned to you.

• Tell your therapist about any concerns, especially if you feel it’s not working or if the therapist isn’t a great fit.

CBT FAQs

Listed below are some of the most commonly asked questions about CBT.

What happens if CBT doesn’t work?

If CBT isn’t working for you, be open and honest with your therapist. They may be able to change the format, exercises, and other factors to make it more effective. You can also look for another therapist who might be a better fit.

Sometimes, CBT doesn’t provide the benefits you’re looking for even after those changes. This is sometimes true with severe depression and other significant concerns. In these cases, you may want to try medication, either alone or in combination with CBT. ^[6]

Is there anyone who shouldn’t use CBT?

CBT may not be recommended for individuals with more severe or complex concerns, such as active suicidal ideation, bipolar disorder, schizophrenia, or individuals with learning disorders. It may also not be suitable for individuals with histrionic personality disorder (or related symptoms) or people still in the midst of intense grief.

Always ask your mental health provider any questions you may have regarding the suitability of CBT for your situation.

Does CBT use positive affirmations?

Certain types of CBT can use positive affirmations. The primary goal is to identify negative thoughts and behaviors and correct these to form more adaptive ones, but positive affirmations may be used in conjunction with other approaches.

Is CBT helpful even without a mental health condition?

Yes, CBT can be helpful for other instances besides mental health conditions. It can be used for sub-clinical mental concerns, such as low self-esteem or relationship problems. And it has also been used for physical concerns, such as IBS and chronic pain. ^[5]

Is it 100% effective?

CBT is not 100% effective for everyone. It depends on your symptoms/conditions, severity, motivation, adherence, and many other factors. To get the most out of CBT, stay consistent, believe it will work, and regularly communicate with your therapist to create the most individualized sessions specific to your needs.