Cognitive Behavioral Therapy (CBT)

Understanding the Fundamentals: A Brief History of CBT 

Back in the 1960s, Dr. Aaron Beck was working as a psychiatrist. He was trying to help people with severe depression. He noticed that the usual methods weren't working as well as he wanted. Digging deeper, he came up with something new – Cognitive-Behavioral Therapy. Or CBT for short. 

Instead of just talking about feelings, Beck focused on how thoughts affect mood. He realized that many of his patients had negative thoughts that kept popping up. These thoughts were about themselves, the world, and the future. 
Beck helped his patients identify and challenge these negative thoughts. As they did this, they started to feel better and cope with life better.  

Today, CBT is widely used by therapists worldwide because extensive research has proven it to work. It was one of the first therapies tested in scientific studies and shown to be effective. 

What Does CBT Treat and Is It Helpful for You Teen? 

Clinicians use CBT for treating many mental health diagnoses, including: 

• Mood disorders 

• Anxiety disorders 

• Grief and loss 

• Obsessive-compulsive disorder (OCD) 

• Trauma 

• ADHD 

• Substance use disorders 

• Eating disorders 

• Conduct disorder and oppositional defiant disorder 

CBT has been well-researched and documented over the past several decades. CBT currently has more studies than any other mode of psychotherapy. Many of these studies suggest that CBT can help significantly improve someone's quality of life. It can be just as helpful, or even more helpful, than other treatments or medications. 

CBT often works better than many other treatments when treating anxiety disorders. And it has lower relapse rates. That's why close to 90% of the approaches endorsed by the American Psychological Association involve CBT.

Understanding CBT: How Simple Thoughts Are Impacting You 

CBT focuses on the dynamic interaction between thoughts, feelings, and behaviors. The core principles of this model include: 

• The three items (thoughts, feelings, and behaviors) are linked. 

• Thoughts are subjective and can, therefore, be challenged or changed. 

• Many negative feelings emerge from negative thought patterns. 

Negative thought patterns often include cognitive distortions. Cognitive distortions are faulty thoughts that feel objective. In reality, they tend to be unhelpful and even harmful. 

Here are some well-known cognitive distortions3: 

All-or-nothing thinking: The world feels black-or-white; there is no in-between. You have either done something perfectly, or you failed. You love someone, or you hate them. This kind of thinking can often trigger chronic lose-lose situations. For example, if you don't have time to clean the whole house, you avoid doing any cleaning at all.  

Mental filter: You focus on negative details and they overshadow everything else. For example, you might receive dozens of five-star reviews on a product you sell. But, if you receive one two-star review, you dwell on it.  

Jumping to conclusions: You assume you know what will happen in the future. For example, you might believe that you'll never find a partner. Even though this thought doesn't have any proof supporting it.  

Emotional reasoning: You think your feelings accurately reflect reality. For example, if you feel inferior, it must mean that you really are incompetent to others. Or, if you think you are dumb, it must indicate you won't ever get a better job. 

"Should" statements: You focus on things you should or shouldn't do. This distortion is largely rooted in either past regret or future anxiety. For example, you might say, I shouldn't have eaten that cookie, which often triggers even more shame and guilt. 

 Personalization: You assume you are overly responsible for a particular event. For example, you might believe that it's your fault if a parent abuses you. 

Overgeneralization: You see any negative event as proof that things will always turn out badly. For example, if someone doesn't want to go on a date with you, you might tell yourself, Of course they don't! Nobody ever wants to go out with me. I'm always being rejected. 

Blaming: You hold other people accountable for your feelings. For example, you might say, " Stop guilting me, " or " You keep trying to upset me!".  In reality, nobody can make you "feel" a certain way—it's your job to control your thoughts and emotions. 

What to Expect in CBT 

CBT is a structured and collaborative treatment. Your therapist will start by going over your history and assessing your key concerns. Then, together, you will decide on your treatment goals. In a way, you'll learn to be your therapist by practicing techniques like:  

Cognitive Restructuring 

Cognitive restructuring (also known as reframing) is a significant part of CBT. It helps you recognize and change negative thoughts into more realistic ones. Doing this regularly can improve your mental health. 

Some therapists use thought records to help you practice cognitive restructuring. A thought record is like a chart where you can track the situation that triggered: 

• your emotions 

• your initial thoughts 

• identify a new, more helpful thought 

. You might fill in these thought records in session. Your therapist might also give them to you as homework. 

You can also practice cognitive restructuring by learning how to examine the evidence (on a scale from 0 to 100%, how positive are you that this thought is real?). You can also learn how to identify exceptions:  when did something good happen when you assumed the worst-case scenario would occur? 

Role-Play Interventions 

Many people enter therapy to improve their social skills. Role-play exercises can help you practice setting boundaries and rehearse other challenging situations. Your therapist will pretend to play the other person, and you will practice what you want to say. 

Mindfulness Skills 

Mindfulness is a crucial concept in CBT (and in many other therapies). In fact, mindfulness-based cognitive therapy (MBCT) blends cognitive techniques with meditation. 

Mindfulness helps you become more aware of the present moment. By practicing it regularly, you can improve your response to different situations. 

Progressive Muscle Relaxation 

Progressive muscle relaxation involves tensing and relaxing different body parts one by one.4 You tighten and release while also concentrating on deep breathing. Therapists often provide audio recordings to guide you through this exercise. 

Guided Imagery  

Guided imagery involves concentrating on a specific scene. An audio recording describes it as a form of meditation. This technique can help lower stress levels and boost concentration. 

Daily Mindfulness  

You can also be mindful during everyday interactions and tasks. For instance, focus on active listening when talking to others. Or remove distractions when working on a task. 

Activity Scheduling 

Depression or anxiety can make prioritizing important tasks difficult. Activity scheduling involves listing the activities you want to do each day/week.  You will then write them down on a calendar. 

Activity scheduling takes the guesswork out of your schedule. You know what lies ahead of you–it's your job to complete those tasks! Your therapist may have you rank how you felt before and after each task. This allows you to track any thoughts or feelings that arise. 

Fear Hierarchy/Successive Approximation 

A fear hierarchy can be helpful for clients with certain anxieties or phobias. It's also known as a successive approximation. You'll take small steps before facing whatever scares you the most. 

For example, let's say you have an immense fear of driving. Yet, you want to conquer this fear because your new job requires a car commute. Your therapist may have you list several steps before actually driving the car: 

• Research and educate yourself about staying safe while driving. 

• Sitting in the car with other people while they drive you. 

• Finding a driving instructor who can confirm your fears. 

• Sitting in the car with your driving instructor as they drive. 

• Sitting in the car and holding the wheel (without turning the car on). 

• Driving around the block with your instructor in the car. 

• Driving three blocks with your instructor in the car. 

• Driving across town with your instructor in the car. 

• Driving on the highway with your instructor in the car. 

• Driving to work alone (and calling a supportive friend afterward). 

As you can see, the sequence of steps may look extensive (and you may add more as you work down the list). However, mastering one skill at a time can help you feel empowered and likely encourage you to keep going.

What Are the End Goals of  CBT? 

Everyone's treatment is different, but during CBT, you will likely learn how to: 

• Identify problems appropriately and quickly. 

• Recognize cognitive distortions as they arise in real-time. 

• Distinguish thoughts from feelings. 

• Avoid jumping to the worst-case scenario. 

• Confront and conquer certain fears. 

• Understand how specific triggers impact your mood. 

• Develop healthier coping skills to manage distress. 

• Set appropriate goals for your future. 

What Are the Risks of CBT? 

All therapies come with risks. It's important to understand those risks before starting treatment.  Your therapist will also review them during the informed consent process. 
First, CBT–like any therapy–can feel vulnerable and uncomfortable. It can be difficult to gain insight into problematic thoughts or troubling feelings. Likewise, feeling safe and open up to your therapist may take time. 

Sometimes CBT feels worse before it feels better. This happens because insight can be painful. Also, recognizing a pattern may feel frustrating, especially if you've tried to change it in the past. 

Finally, all change can be frightening, even when the change is positive. Learning new skills and implementing them in your routine takes time and willingness. 
 With that said, the benefits likely outweigh most of these risks. Most people report significant improvements after completing CBT. 

Is CBT the Right Approach for Your Child?

CBT can be a beneficial approach for anyone struggling with chronic negative thoughts. It can also be helpful if you notice a pattern affecting your quality of life. Unfortunately, we often engage in certain behaviors and can't stop, even when we really want to stop.  

First, CBT requires a client's willingness: your therapist cannot do the work for you. You need to have an active, motivated role. This therapy isn't a quick fix, although you will likely experience relief within a few weeks or months. 

To make the most out of CBT, try to be as honest with your therapist as possible. If something isn't working, let them know. If you're feeling worse, speak up about it. Try your best to stay open to learning and integrating the skills you gain outside of the session. 

Remember that your therapist may also provide other referrals for your care. For example, they may deem meeting with a psychiatrist, medical doctor, or dietician important. If that's the case, make an effort to work with your treatment team. Doing so should ensure the best outcome for your success. 

When Isn't CBT Appropriate? 

CBT isn't appropriate for everyone. You may need a different mode of treatment if you struggle with: 

• Ongoing, recurrent suicidal ideation 

• Active psychosis 

• Severe substance use 

• Severe eating disorders 

If these apply to you, your therapist may recommend a higher level of care before intervention. This higher level of care can assist you in achieving stability and safety.  Once you've completed this care, you may then be ready to begin CBT. 

Likewise, some individuals prefer different forms of therapy instead of CBT. If you are struggling with trauma, you may benefit more from EMDR. You might consider working with an art therapist if you have a hard time talking about your feelings. 

How Long Does CBT Take? 

There isn't a one-size-fits-all recommendation for the length of CBT. CBT usually entails one session a week over 12–20 weeks.5 Intensive CBT (I-CBT) is much faster, as it consists of longer sessions occurring within just a week or day. Some therapists will complete this treatment in as little as one eight-hour session. 

Many variables can affect the length of treatment, including: 

• One's motivation for treatment and recovery. 

• Presence of co-occurring mental health conditions. 

• History of CBT or other therapies in the past. 

• How quickly the therapist and client build trust and rapport. 

What Other Therapies Are Available? 

Several treatments integrate cognitive or behavioral elements. Also, some therapists blend different techniques based on your specific goals. 

Dialectical Behavioral Therapy (DBT) 

DBT and CBT are quite similar. DBT focuses on the core principles of mindfulness, emotional regulation, and distress tolerance. DBT is often the gold standard of treatment for borderline personality disorder. Yet, it can also be used to treat other mental health issues or compulsions. Learn more about DBT at Idaho Youth Ranch. 

Schema Therapy 

Schema therapy combines CBT, psychoanalysis, and attachment theory. Schemas are the negative patterns people develop as a result of their unmet needs. These negative patterns impact your quality of life. Schema therapy can help you challenge and heal them, thereby addressing past issues. 

Acceptance and Commitment Therapy (ACT) 

CBT focuses on challenging and changing negative thoughts. ACT focuses more on accepting them. You will learn acceptance through integrating more mindfulness and self-compassion. The idea is that by becoming more tolerant of your emotions, you can improve your feelings about yourself and the world around you. 

Rational Emotive Behavior Therapy (REBT) 

REBT also focuses on recognizing negative thoughts and feelings. You will learn how your thoughts play a role in your  emotional problems. By breaking this pattern, you can learn how to change your responses.