Cognitive Behavioral Therapy

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Intro to Cognitive Behavioral Therapy

Cognitive Behavioral Therapy (CBT) is one of the most widely used and respected types of contemporary psychotherapy. Although CBT is a general term that can refer to various therapy types based on similar principles, its origins can be traced to Cognitive Therapy (CT), developed by Aaron Beck in the 1960s, and Rational Emotive Therapy (REBT), developed by Albert Ellis in the 1950s. CT is based on the principle that our thoughts (cognition), feelings (emotion), and actions (behavior) are all interrelated, so if we change our thoughts and behaviors, we can also change the way we feel. REBT is based on the ABC model (A is an Activating event, B is a Belief, and C refers to Consequences). According to this model, an activating event (A) will trigger a belief (B) held by a person, and this belief leads to a consequence (C; i.e., a reaction to the activating event). This model holds that irrational beliefs are usually the culprits that make our problems feel worse. The consequences of our beliefs can be healthy if our beliefs are rational or unhealthy if our beliefs are irrational. CBT can help you evaluate your thoughts and behaviors and restructure them, as needed, to experience yourself, others, and the world in more adaptive ways that can improve your quality of life.  

CBT is especially effective for treating depression and anxiety, but it’s just as often used to treat a broad range of psychological symptoms and disorders. It is, typically, short-term, goal-oriented, and collaborative. Sessions are structured. At the beginning of therapy, the client and therapist set the goals they will work towards. Next, a treatment plan is developed, and at the beginning of each session thereafter, the client and therapist collaborate to decide on which topic(s) they will work on that day. Therapists often utilize worksheets and assign homework. Therapy can be completed in as few as six sessions, typically around 50-minutes each; however, those working through more complex problems may find themselves needing ongoing treatment for a year or more.  

Although CBT provides tools for tackling negative thoughts, it recognizes that unpleasant circumstances do happen. However, when one isn’t thinking clearly, our negative thinking can make matters worse, and we may fail to see the good in a situation or the solutions to our problems. CBT is an approach to minimize these misinterpretations so that you can optimize your life and circumstances. The treatment is tailored to each client’s individual needs, and the ultimate aim is to give clients the skills to become their own therapist. It can be used in individual, group, and family therapy settings. There are also many self-help books and online resources available if you are not yet ready to commit to seeing a therapist.  

You might be seeking therapy to help with symptoms of a psychological disorder, or you might be an otherwise highly functioning and well-adapted individual who finds yourself battling an inner critic or other self-limiting beliefs. Whatever the case, CBT can be a helpful tool for evaluating the assumptions and core beliefs that underlie your thoughts, feelings, and behaviors. It can result in a reduction in symptoms and/or improved overall wellbeing. If you decide you’d like to give CBT a try, whether you choose to see a therapist or try it on your own, CBT will work best if you are motivated and committed to actively participating in your healing journey.       

Origins of Cognitive Behavioral Therapy

Cognitive Therapy (CT) was developed in the 1960s by Aaron Beck to advance Albert Ellis’ Rational Emotive Behavior Therapy (REBT) that was developed in the ‘50s. Beck and Ellis were both psychiatrists practicing psychoanalysis, and both were dissatisfied with the results they were seeing with their patients. Moreover, both of these men observed specific patterns among their patients that they believed should be the real focus of psychotherapy. Shifting the focus from childhood family dynamics (as is a primary focus in psychoanalysis) to the present, Ellis considered our philosophies and beliefs to be predominantly responsible for how we think, feel, and behave. If we hold irrational beliefs and maladaptive attitudes, then our feelings and behaviors will consequently suffer as a result. Similarly, Beck noticed a strong connection between thoughts, feelings, and behaviors. He observed negative thinking patterns in his patient’s internal dialogue (i.e., “negative self-talk”) that seemed to result in negative feelings and unhealthy behaviors.     

These observations led to what was then a revolutionary approach to psychotherapy. Ellis used the Socratic method (a method of questioning developed by Socrates in Ancient Greece) to evaluate his patient’s belief systems and philosophies. He believed that one’s circumstances are not the cause of symptoms, but that one’s perceptions of their circumstances cause symptoms. So, by recognizing how our beliefs influence our perceptions, we can then change our thoughts, feelings, and behaviors to reduce symptoms. Similarly, Beck observed that many of his patients expressed emotionally charged thoughts in response to various triggers. He referred to these as “automatic thoughts,” and his approach aimed to help his patients to identify, understand, and manage them using a combination of cognitive and behavioral techniques, hence the name Cognitive Behavioral Therapy (CBT). 

Although CBT was developed decades ago, it is continually updated in response to empirical research. Beyond its origins of REBT and CT, CBT is influenced by many modalities, such as: 

Dialectical Behavior Therapy (CBT) | Acceptance and Commitment Therapy (ACT)  | Gestalt Therapy | Compassion-Focused Therapy | Mindfulness-Based Therapy (MBT) | Solution-Focused Brief Therapy (SFBT)  | Motivational Interviewing | Positive Psychology | Interpersonal Psychotherapy | Psychodynamic psychotherapy (particularly with respect to personality disorders)

Summary of CBT: What is CBT?

The main idea behind CBT is that our thoughts, feelings, and behaviors are all interrelated, so when our thinking is irrational or distorted, it adversely affects our feelings and behaviors. By reflecting on patterns in our self-talk (internal dialogue), the CBT approach helps bring our automatic thoughts into awareness to consciously evaluate them and change those that negatively impact our lives. CBT was initially developed by observing irrational beliefs and automatic thoughts in depressed patients. Beck identified three key elements of negative thinking known as the Cognitive Triad. The Cognitive Triad identifies how three types of automatic negative thinking interact (i.e., negative thoughts about the self, the world, the future), which is especially typical of clients with depression. This interaction can lead to negative biases in perception, problem-solving, and memory, sometimes leading to perseveration and rumination. 

Because these negative thinking patterns were first identified in patients working through depression, CBT was initially developed to treat people who suffered from depression. However, CBT has long since been effectively used to treat many symptoms and disorders, including:

Depression

Anxiety and Panic Disorders

Substance Abuse and Addiction 

Eating Disorders

Anger Management

Obsessive-Compulsive and Tic Disorders

Child and Adolescent problems

Chronic Fatigue Syndrome

Chronic Pain

Habits

Emotional Dysregulation and Mood Swings

Phobias

Sexual and Relationship problems

Sleep Disorders

Interpersonal relationships and communication

General health problems

Additionally, the following symptoms and disorders might be effectively treated with CBT as well, but with some caveats:

Trauma and Posttraumatic Stress Disorder (PTSD) – Although CBT can help treat trauma and PTSD, it is recommended that potential clients seek a practitioner trained in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), which was developed specifically to support the needs of trauma survivors; however, there are many other trauma-informed treatments available that may be more effective depending on symptom severity and other needs. 

Schizophrenia and Psychotic disorders – Although not typically recommended as a stand-alone treatment, CBT combined with medication may help treat individuals who suffer from hallucinations, delusions, and other psychotic symptoms.

If you experience any of these symptoms or disorders, CBT might be for you if you prefer a present-oriented, structured, practical, and action-based approach to psychotherapy. CBT will more likely help individuals who prefer a problem-solving approach and who are motivated to participate in therapy through assignments and homework actively. Assignments are designed to help clients recognize how stressors in their lives can trigger unhealthy thinking patterns resulting in their symptomatic feelings and behaviors. It’s important to understand that CBT does not work on processing feelings or changing them directly. Instead, CBT aims to indirectly improve mood and feelings and reduce symptoms by helping clients change unhelpful ways of thinking that are believed to result in negative feelings and unhealthy behaviors. Homework is assigned so that the client can practice skills learned in therapy in their daily lives outside of the therapy session. You can think of it as an experiment in which you can see how changing one variable (your thoughts and/or behaviors) can affect the other variables (thoughts, behaviors, and feelings).

In the CBT model, there are five areas believed to be interconnected: situations, thoughts, emotions, physical feelings, and behaviors. CBT works by breaking down problems so that the client can work on each of these parts, with the main emphasis on distorted thinking. According to the cognitive approach to therapy, mental illness results from flaws in how we think about ourselves, others, and the world. These flaws include cognitive deficiencies (such as poor planning) or cognitive distortions (inaccurate or irrational information processing). These flawed mental representations then influence our perceptions about the world, which can cyclically reinforce one’s distorted experiences and expectations, negative feelings, and unhealthy or self-defeating behaviors. However, because we aren’t always aware of our automatic thoughts and underlying core beliefs, we must learn to identify them. So, when a client comes into therapy feeling upset in some way, a CBT therapist will help clients to learn how to identify triggers and unhelpful thoughts at several levels (i.e., automatic thoughts, intermediary thoughts, and core beliefs). Once we understand the interrelationship between Automatic Thoughts (spontaneous thoughts that arise in response to triggers), Intermediary Beliefs (our rules, attitudes, and assumptions used to make sense of the world), and Core Beliefs (deeply held beliefs about ourselves, others, and the world that tend to be rigid and overgeneralized), then we can then challenge these thoughts and beliefs and replace them with more realistic and adaptive perspectives and beliefs. According to CBT, this is key to understanding and overcoming symptoms to achieve lasting symptoms reduction, improvement in mood and functioning, and overall wellbeing. 

Negative Self-Schemas are negative core beliefs about the self that can result in several cognitive distortions (unhelpful thinking styles). The following is a list of some of the most common cognitive distortions experienced by many people:

Arbitrary inference: Interpreting a situation, event, or experience in a certain way, even when there is no evidence supporting the conclusion, or the evidence contradicts the conclusion

Selective abstraction: Focusing on a detail taken out of context, ignoring other information, and conceptualizing one’s whole experience based on this detail

Overgeneralization: Drawing a general conclusion or rule about self, other, or circumstances based on a single event

Catastrophizing: Expecting worst-case scenarios 

Magnification/Minimization: Extreme errors in evaluation

Filtering: focusing on negatives while ignoring positives

Black-and-White thinking: All-or-nothing thinking

Heaven’s reward fallacy: The expectation that self-sacrifice should be rewarded

Control fallacies: Assumes only others to blame or assumes only self to blame

Always being right: Being wrong is unacceptable

Fallacy of fairness: Assumption that life should always be fair

Personalization Always assuming self-responsible

Jumping to conclusions: Making assumptions based on little evidence

Emotional reasoning: “If I feel it, it must be true”

Blaming: Placing blame on others, does not accept responsibility for self

Fallacy of change: Expects others to change 

Global labeling: Extreme generalization

Shoulds: Judges self and others if personal rules of values or conduct are broken

In addition to teaching clients how to identify cognitive distortions, new coping skills, and how to modify their thoughts, beliefs, and behaviors, clients may experience a new form of relationship with their therapist they may not have had before. The therapeutic alliance is one of the most essential components of cognitive therapy. The therapist will frequently ask the client for feedback and their views about what is going on in treatment. CBT can provide a non-judgmental and collaborative relationship in which clients are actively involved in developing their own treatment plans.  

If you decide to see a CBT therapist, their approach to treatment can be broken down and summarized according to a few basic ideas:

Cognitive formulation – This is the therapist’s initial assessment, diagnoses, and behavioral strategies formulated for specific symptoms and disorder(s).

Case Conceptualization – The therapist’s understanding of an individual client and their beliefs and/or patterns of behavior underlying their symptoms. In CBT, there are four “P’s” in Case Conceptualization that can help the therapist to conceptualize this; that is, Predisposing factors (internal or external risk factors), Precipitating factors (triggers); Perpetuating factors (reinforces the problem); and Protective factors (strengths, supports, and adaptive patterns)

Cognitive Model – The CBT therapist’s case conceptualization will be based on the Cognitive Model, which seeks to identify their client’s automatic thoughts and cognitive distortions, and how these influence or distort a client’s perception of situations.

Although the theory behind CBT might sound straightforward, many techniques are applied and taught by skilled therapists. A few of these techniques include:

ABC Functional Analysis (as adapted from REBT), which helps the client identify Antecedents, Behaviors, and Consequences.

The Dysfunctional Thought Record helps clients to identify when and why negative thoughts are most likely to occur. 

The Fact-Checking exercise helps clients to recognize their emotionally charged thoughts and to differentiate them from facts.

The Cognitive Restructuring worksheet uses Socratic questioning to challenge irrational or illogical thoughts and beliefs. 

CBT employs many interventions. A few of these might include:

Self-care or other enjoyable activities

Identifying and reflecting on successes

Monitoring mood

Relaxation techniques

Problem-solving

Tools often used in CBT include: 

Cognitive restructuring: Explores causes and patterns of cognitive distortions, then reframes and restructures them

Unraveling cognitive distortions: Identifying and challenging faulty thinking

Journaling: Self-reflection; identify thought patterns

Breathing exercises: Helps to ground and re-center

Play the script until the end: Coping skill to help clients explore the worst-case scenarios in fear or anxiety-provoking situations

Progressive muscle relaxation: Guided meditation that helps clients relax each muscle group throughout the body from feet to head, bringing awareness and release to places of tension

Nightmare exposure and re-scripting: Helps clients develop new responses to nightmares 

CBT Activities:

Mindfulness meditation: Helps clients stay focused on the present moment instead of focusing on ruminations (helps with depressions, anxiety, addiction)

SMART goals/Successive approximation: Helps clients to break down large tasks into smaller, more manageable steps (SMART = Specific, Measurable, Attainable, Realistic, Time-bound)  

Reframing: Changing one’s perspective in how situations and experiences are viewed

Gratitude meditation: Reflecting on or writing down things you are thankful for

Positive affirmations/self-statements: Daily mantras that reinforce positive and empowering things about oneself

Homework: Clients are sometimes assigned exercises between therapy sessions to help them practice skills learned in therapy.

Ultimately, CBT’s goals are to help clients learn to recognize and evaluate the relationship between their thoughts, feelings, and behaviors to modify them as needed and empower clients to continue using these skills independently. In addition, the client is given tools and resources to identify their own cognitive distortions and restructure or reframe faulty thinking that they can use even after therapy has been terminated.   

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Research & Science supporting CBT​

CBT is one of the most extensively researched and empirically validated types of psychotherapy. It has been shown to be effective in over 2,000 research studies. For example, Butler and Beck (2000) performed fourteen meta-analyses (i.e., they analyzed the statistical results from fourteen previous studies) on CBT’s effectiveness and found that 80% of adults benefited from it. More specifically, research supports CBT’s effectiveness for treating depression (Hollon & Beck, 1994) and anxiety (Beck, 1993). Hofmann et al. (2012) analyzed the results from 106 previous studies on CBT. They found the strongest support for CBT’s effectiveness in treating anxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress. In addition, follow-up studies show that CBT clients had reduced symptoms two years after they completed therapy.     

The research referenced is cited here if you are interested in reading about these studies more in-depth:

Beck, A. T. (1993). Cognitive approaches to stress. In R. Woolfolk & P. Lehrer (Eds.), Principles and practice of stress management (2nd ed., pp. 333-372). New York: Guilford.

Butler, A. C., & Beck, J. S. (2000). Cognitive therapy outcomes: A review of meta-analyses. Journal of the Norwegian Psychological Association, 37(1), 1-9.

Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. 2013. The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognit Ther Res. 36(5): 427–440.    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584580/ 

Hollon, S. D., & Beck, A. T. (1994). Cognitive and cognitive-behavioral therapies. In A.E. Bergin & S.L. Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed., pp. 428-466). New York: Wiley.

The Seeker Experience

Since CBT is a goal and action-oriented type of therapy that requires commitment and motivation, first reflect on your readiness to actively participate in this type of therapy so you can get the most out of it. If you feel depressed and unmotivated, that statement isn’t meant to discourage you (remember, CBT can be especially effective in treating depression). Having a genuine desire to heal can be enough, but ask yourself how much you are willing to engage with the healing process and how you feel about potentially doing exercises and activities outside of the therapy sessions. 

Suppose you decide to give CBT a try. Your initial session should involve:

Establishing a sense of trust with your therapist.

Completing an assessment(s).

Identifying problems and goals you wish to work on.

The CBT therapist is trained to listen for clues into how your thinking might adversely affect your life and develop a treatment plan. At the start of each session thereafter, you and the therapist will decide on which problem(s) you want to work on that day. Your therapist will then help you with problem-solving and teaching skills to help you to evaluate your thinking and change unwanted/unhelpful behaviors. In the end, you should, ideally, come away with a skill set that you can practice on your own.

Here are some personal experiences shared by Seekers who have tried CBT therapy:

Finding a Guide & Guide Perspectives

Although there are plenty of self-help books and online resources, there is little research on CBT’s effectiveness outside of a clinical setting. However, ample research supports CBT’s effectiveness when practiced with a trained mental healthcare provider. CBT can be learned and used by all mental healthcare practitioners, such as therapists, psychiatrists, counselors, social workers, and coaches. There is no license required to practice CBT, but some practitioners who have received special training may have a certification added to their credentials. Drs. Aaron and Judith Beck, along with other leading CBT practitioners, developed a certification program at the Beck Institute; again, CBT was developed by Aaron Beck, and the Beck Institute touts offering the highest level of training and claims their graduates as the best in the field. However, many graduate programs and internships specialize their clinical programs to educate and train students in CBT. If you feel a practitioner might be a good fit and they don’t have a certification listed, you can ask them about their training background and/or look into their school. Most importantly, as with any therapy, be sure to find someone you feel you can connect with and with whom you feel safe, supported, and understood.  

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Potential Drawbacks/Criticisms

While CBT’s focus on thinking is one of its strengths, some people also consider it one of its weaknesses. Although a good therapist will be supportive, some clients prefer a more process-oriented type of therapy that is less structured and more focused on how a person is feeling. Also, CBT is present-focused, so it can be argued that CBT doesn’t actually get to the root of one’s problems, but just the symptoms, which can then manifest in other ways. Moreover, it’s harder to solve more severe or deeply rooted symptoms and issues in what is typically short-term therapy. Also, while some consider homework assignments to be a strength, it’s not for everyone, so that should be considered before choosing this modality. 

On the other hand, here are some of CBT’s strengths for your consideration. One of CBT’s strengths is its focus on teaching clients how to recognize when their thinking is faulty and how it contributes to their problems or symptoms. CBT offers many tools to help people change their thoughts and behaviors, improving their mood and wellbeing. CBT introduces clients to a skillset that they can apply whenever they need to, even after therapy ends. Another advantage to CBT is that it can be completed in a relatively short amount of time compared with other types of treatment (it can be completed in as few as 6 – 8 sessions, but it tends to last 5 – 10 months on average). In addition, most CBT practitioners customize their treatment plans to the specific needs of each client. Finally, because CBT is evidence-based, it is widely used because it’s been shown to be effective, especially for treating depression and anxiety, and follow-up studies show a lasting reduction of symptoms years later.

Works Cited

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Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. 2013. The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognit Ther Res. 36(5): 427–440. [Accessed 28 January 2021].

Mayoclinic.org. 2021. Cognitive behavioral therapy – Mayo Clinic. [online] Available at: <https://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/about/pac-20384610> [Accessed 28 January 2021].

Mishlove, J, & Ellis, A.. 2017. Albert Ellis: A Guide to Rational Living – Thinking Allowed DVD w/ Jeffrey Mishlove. [Video] Available at: < https://youtu.be/GyRE-78g_z0> [Accessed 28 January 2021].

Psych Central. 2021. In-Depth: Cognitive Behavioral Therapy. [online] Available at: <https://psychcentral.com/lib/in-depth-cognitive-behavioral-therapy/> [Accessed 28 January 2021].

PositivePsychology.com. 2021. 25 CBT Techniques and Worksheets for Cognitive Behavioral Therapy. [online] Available at: <https://positivepsychology.com/cbt-cognitive-behavioral-therapy-techniques-worksheets/> [Accessed 28 January 2021].

PositivePsychology.com. 2021. CBT Explained: An Overview and Summary of CBT (Incl. History). [online] Available at: <https://positivepsychology.com/cbt/> [Accessed 28 January 2021].

Psychology Today. 2021. Trauma-Focused Cognitive Behavior Therapy. [online] Available at: <https://www.psychologytoday.com/us/therapy-types/trauma-focused-cognitive-behavior-therapy> [Accessed 28 January 2021].

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Verywell Mind. 2021. How Cognitive Behavior Therapy Works. [online] Available at: <https://www.verywellmind.com/what-is-cognitive-behavior-therapy-2795747> [Accessed 28 January 2021].

Youtility. 2017. Cognitive Behavior Therapy (CBT) Overview. [Video] Available at:  https://www.youtube.com/watch?v=UDXQUVQdFHA> [Accessed 28 January 2021].