Cognitive Behavioral Therapy (CBT)

Cognitive-behavioral therapy (CBT) is a well-known, evidence-based psychotherapy used to treat numerous mental health conditions and emotional problems.1 CBT focuses on the relationship between thoughts, feelings, and behavior. The overarching premise focuses on increasing insight—by becoming more aware of your patterns, you can learn to change how you respond to challenging emotions.

  

A Brief History of CBT

Dr. Aaron Beck developed the foundation for CBT in the 1960s. At the time, he worked as a psychiatrist providing psychoanalysis for individuals struggling with severe depression. In his research, Beck discovered that standard psychoanalytic techniques weren’t yielding the same results he hoped for in treating depression.2

Instead, he began observing how most of his depressed patients experienced ongoing series of automatic negative thoughts. These thoughts fell into three distinct categories: negative thoughts about themselves, the world around them, and the future.

Beck started helping his patients recognize, label, and assess these automatic thoughts. Through this process, he found they could think about the situation more realistically. Subsequently, they began feeling better and functioned more appropriately.

 Today, there are thousands of studies backing the efficacy of CBT. Practitioners across the world use it in treating clients of all ages and demographics. CBT was the first mode of therapy tested with rigorous criteria (randomized trials, control groups, etc.). Therefore, it was the first treatment model primarily identified as evidence-based.


What Does CBT Treat?

Clinicians use CBT for treating numerous 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

Similarly, many clinicians integrate CBT with other treatments as part of their practice. Even if you don’t have a specific diagnosis, it’s common for therapists to use CBT to help you recognize problematic patterns and strengthen your self-esteem.

CBT can occur in either individual or group sessions. Some family and couples therapists also use CBT techniques when intervening with more than one person.


Understanding the Premise of CBT

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 interconnected.
  • 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 hone in on negative details to the point where they overcast 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. So, for example, you might believe that you’ll never find a partner, even though this thought doesn’t have any objective evidence supporting it. 

Emotional reasoning: You assume your feelings are indicative of objective 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 perceive any adverse event as reinforcement that things will always end poorly. 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 something like, Stop guilting me, or, You keep trying to get me upset! In reality, nobody has the power to 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 begin your work by reviewing your history and assessing your key concerns. Then, together, you will decide on your treatment goals. In a sense, you will eventually learn how to act like your own therapist by using some of the following techniques:

Cognitive Restructuring

Cognitive restructuring (also known as reframing) is a significant part of CBT. This technique allows you to identify and challenge negative thoughts into more realistic ones. Practicing it consistently will enable you to improve your overall mental health. 

Some therapists use thought records to help you practice cognitive restructuring. A thought record is a visual graph that allows you to chart the triggering situation, original emotion, and thought, and then identify a new thought. You might fill in these thought records in session, or your therapist may assign them 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 allows you to become more conscious and aware of the present moment. Over time, integrating more mindfulness can help you strengthen how well you respond to various situations.

Progressive muscle relaxation: Progressive muscle relaxation entails constricting and then releasing different body parts systematically.4 You will tighten and release as you also focus on deep breathing. Many therapists use an audio recording to help you practice this skill.

Guided imagery: Guided imagery entails focusing on a particular scene (often described in an audio recording) as a way of meditating. This technique can help lower stress levels and boost concentration.

Daily mindfulness: You can also be mindful during everyday interactions and tasks. For example, you may practice more active listening when speaking to others, or you might eliminate distractions when you focus on a specific chore.

Activity Scheduling

Depression or anxiety can make prioritizing important tasks difficult. Activity scheduling requires you to indicate which activities you want to complete in a day or week. You will then write them down on a calendar.

Activity scheduling essentially 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 (also known as successive approximation) can be helpful for clients with certain anxieties or phobias. This intervention allows you to confront your fear slowly. You will essentially take many baby steps before addressing 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:

  • Researching and educating yourself about staying safe while driving.
  • Sitting in the car with other people while they drive you.
  • Finding a driving instructor who can validate 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). But mastering one skill at a time can help you feel empowered, and it will 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 have some inherent risks, and it’s crucial 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, it may take time to feel safe and open up to your therapist.

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 You?

CBT can be a beneficial approach for anyone struggling with chronic negative thoughts. It can also be highly effective if you recognize a problematic 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 and foremost, 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.

Keep in mind that your therapist may also provide other referrals for your care. For example, they may deem it important to meet with a psychiatrist, medical doctor, or dietician. 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. A higher level of care can help you achieve stabilization and safety. After that care is completed successfully, you may be an appropriate candidate for CBT.

Likewise, some individuals prefer different forms of therapy instead of CBT. For instance, if you are struggling with trauma, you may benefit more from EMDR (a trauma-based treatment). Or, if you have difficulty talking about your feelings, you might consider working with an art therapist.


How Long Does CBT Take?

There isn’t a one-size-fits-all recommendation for the length of CBT. However, traditional 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.

Numerous 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 Similar to CBT?

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

Dialectical Behavioral Therapy (DBT)

DBT and CBT are quite similar, but DBT focuses more on the core principles of mindfulness, emotional regulation, and distress tolerance. DBT is often the gold standard of treatment for borderline personality disorder. However, 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 schemas adversely affect your quality of life, so schema therapy can help you challenge and heal these schemas as a way of healing your past.

Acceptance and Commitment Therapy (ACT)

While 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 premise is that increasing tolerance for your emotions allows you to feel better about yourself and the world.

Rational Emotive Behavior Therapy (REBT)

REBT also focuses on recognizing negative thoughts and feelings. You will learn how your thoughts contribute to emotional problems, and by breaking this pattern, you can learn how to change your responses.


What Are the Benefits of TF-CBT?

Empirical data shows TF-CBT as a highly effective treatment model for youth. Such findings consistently highlight how TF-CBT can reduce PTSD, depression, and behavioral symptoms in children who have experienced trauma. 

TF-CBT has been proven to specifically help with:5

  • Experiencing fewer intrusive thoughts and avoidance behaviors.
  • Increased ability to withstand and cope with traumatic reminders.
  • Decreased PTSD symptoms (depression, anxiety, dissociation, behavior problems).
  • Increased sense of interpersonal trust and social competence.
  • Increased awareness of personal safety.
  • Increased ability to manage future trauma triggers.

Similarly, parents appear to yield similar benefits. Research shows that parents tend to report reduced rates of depression and PTSD. They tend to indicate having a better understanding of their child’s situation, and they rate themselves as more capable of supporting their children.


What Does the Research on CBT Tell Us?

CBT has been well-researched and documented over the past several decades. In fact, CBT currently has more studies than any other mode of psychotherapy.6

Many of these studies suggest that CBT can help significantly improve someone’s quality of life. It can be just as beneficial (or even more beneficial) than other treatments or psychiatric medications.

CBT frequently outperforms most other treatments when treating anxiety disorders. It also has lower relapse rates than most other models.7 Therefore, it should come as no surprise that almost 90% of the approaches supported by the American Psychological Association involve CBT.8


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