Cbt what is it

What Is Cognitive Behavioral Therapy (CBT)?

Kendra Cherry, MS, is an author and educational consultant focused on helping students learn about psychology.

Rachel Goldman, PhD FTOS, is a licensed psychologist, clinical assistant professor, speaker, wellness expert specializing in eating behaviors, stress management, and health behavior change.

Verywell / Daniel Fishel

What Is Cognitive Behavioral Therapy?

Cognitive behavioral therapy (CBT) is a type of psychotherapeutic treatment that helps people learn how to identify and change the destructive or disturbing thought patterns that have a negative influence on their behavior and emotions.

CBT Definition

Cognitive behavioral therapy is defined as «psychotherapy that combines cognitive therapy with behavior therapy by identifying faulty or maladaptive patterns of thinking, emotional response, or behavior and substituting them with desirable patterns of thinking, emotional response, or behavior.»

Cognitive behavioral therapy focuses on changing the automatic negative thoughts that can contribute to and worsen our emotional difficulties, depression, and anxiety. These spontaneous negative thoughts also have a detrimental influence on our mood.

Through CBT, faulty thoughts are identified, challenged, and replaced with more objective, realistic thoughts.

Everything You Need to Know About CBT

This video has been medically reviewed by Steven Gans, MD.

Types of Cognitive Behavioral Therapy

CBT encompasses a range of techniques and approaches that address our thoughts, emotions, and behaviors. These can range from structured psychotherapies to self-help practices. Some of the specific types of therapeutic approaches that involve cognitive behavioral therapy include:

While each type of cognitive behavioral therapy takes a different approach, all work to address the underlying thought patterns that contribute to psychological distress.

Cognitive Behavioral Therapy Techniques

CBT is about more than identifying thought patterns. It uses a wide range of strategies to help people overcome these patterns. Here are just a few examples of techniques used in cognitive behavioral therapy.

Identifying Negative Thoughts

It is important to learn what thoughts, feelings, and situations are contributing to maladaptive behaviors. This process can be difficult, however, especially for people who struggle with introspection. But taking the time to identify these thoughts can also lead to self-discovery and provide insights that are essential to the treatment process.

Practicing New Skills

In cognitive behavioral therapy, people are often taught new skills that can be used in real-world situations. For example, someone with a substance use disorder might practice new coping skills and rehearse ways to avoid or deal with social situations that could potentially trigger a relapse.

Goal-Setting

Goal setting can be an important step in recovery from mental illness, helping you to make changes to improve your health and life. During cognitive behavioral therapy, a therapist can help you build and strengthen your goal-setting skills.

This might involve teaching you how to identify your goal or how to distinguish between short- and long-term goals. It may also include helping you set SMART goals (specific, measurable, attainable, relevant, and time-based), with a focus on the process as much as the end outcome.

Problem-Solving

Learning problem-solving skills during cognitive behavioral therapy can help you learn how to identify and solve problems that may arise from life stressors, both big and small. It can also help reduce the negative impact of psychological and physical illness.

Problem-solving in CBT often involves five steps:

Self-Monitoring

Also known as diary work, self-monitoring is an important cognitive behavioral therapy technique. It involves tracking behaviors, symptoms, or experiences over time and sharing them with your therapist.

Self-monitoring can provide your therapist with the information they need to provide the best treatment. For example, for people with eating disorders, self-monitoring may involve keeping track of eating habits, as well as any thoughts or feelings that went along with consuming a meal or snack.

Additional cognitive behavioral therapy techniques may include journaling, role-playing, engaging in relaxation strategies, and using mental distractions.

What Cognitive Behavioral Therapy Can Help With

Cognitive behavioral therapy can be used as a short-term treatment to help individuals learn to focus on present thoughts and beliefs.

CBT is used to treat a wide range of conditions, including:

In addition to mental health conditions, cognitive behavioral therapy has also been found to help people cope with:

Benefits of Cognitive Behavioral Therapy

The underlying concept behind CBT is that thoughts and feelings play a fundamental role in behavior. For example, a person who spends a lot of time thinking about plane crashes, runway accidents, and other air disasters may avoid air travel as a result.

The goal of cognitive behavioral therapy is to teach people that while they cannot control every aspect of the world around them, they can take control of how they interpret and deal with things in their environment.

CBT is known for providing the following key benefits:

One of the greatest benefits of cognitive behavioral therapy is that it helps clients develop coping skills that can be useful both now and in the future.

Effectiveness of Cognitive Behavioral Therapy

CBT emerged during the 1960s and originated in the work of psychiatrist Aaron Beck, who noted that certain types of thinking contributed to emotional problems. Beck labeled these «automatic negative thoughts» and developed the process of cognitive therapy.

Where earlier behavior therapies had focused almost exclusively on associations, reinforcements, and punishments to modify behavior, the cognitive approach addresses how thoughts and feelings affect behaviors.

Today, cognitive behavioral therapy is one of the most well-studied forms of treatment. It has been shown to be effective in the treatment of a range of mental conditions, including anxiety, depression, eating disorders, insomnia, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, and substance use disorder.

CBT is one of the most researched types of therapy, in part, because treatment is focused on very specific goals and results can be measured relatively easily.

Verywell Mind’s Cost of Therapy Survey, which sought to learn more about how Americans deal with the financial burdens associated with therapy, found that Americans overwhelmingly feel the benefits of therapy:

Things to Consider With Cognitive Behavioral Therapy

There are several challenges that people may face when engaging in cognitive behavioral therapy. Here are a few to consider.

Change Can Be Difficult

Initially, some patients suggest that while they recognize that certain thoughts are not rational or healthy, simply becoming aware of these thoughts does not make it easy to alter them.

CBT Is Very Structured

Cognitive behavioral therapy doesn’t focus on underlying, unconscious resistance to change as much as other approaches such as psychoanalytic psychotherapy. Instead, it tends to be more structured, so it may not be suitable for people who may find structure difficult.

You Must Be Willing to Change

For cognitive behavioral therapy to be effective, you must be ready and willing to spend time and effort analyzing your thoughts and feelings. This self-analysis can be difficult, but it is a great way to learn more about how our internal states impact our outward behavior.

Progress Is Often Gradual

In most cases, CBT is a gradual process that helps you take incremental steps toward behavior change. For example, someone with social anxiety might start by simply imagining anxiety-provoking social situations. Next, they may practice conversations with friends, family, and acquaintances. By progressively working toward a larger goal, the process seems less daunting and the goals easier to achieve.

How to Get Started With Cognitive Behavioral Therapy

Cognitive behavioral therapy can be an effective treatment choice for a range of psychological issues. If you or someone you love might benefit from this form of therapy, consider the following steps:

What to Expect With Cognitive Behavioral Therapy

If you’re new to cognitive behavioral therapy, you may have uncertainties or fears of what to expect. In many ways, the first session begins much like your first appointment with any new healthcare provider.

During the first session, you’ll likely spend some time filling out paperwork such as HIPAA forms (privacy forms), insurance information, medical history, current medications, and a therapist-patient service agreement. If you’re participating in online therapy, you’ll likely fill out these forms online.

Also be prepared to answer questions about what brought you to therapy, your symptoms, and your history—including your childhood, education, career, relationships (family, romantic, friends), and current living situation.

Once the therapist has a better idea of who you are, the challenges you face, and your goals for cognitive behavioral therapy, they can help you increase your awareness of the thoughts and beliefs you have that are unhelpful or unrealistic. Next, strategies are implemented to help you develop healthier thoughts and behavior patterns.

During later sessions, you will discuss how your strategies are working and change the ones that aren’t. Your therapist may also suggest cognitive behavioral therapy techniques you can do yourself between sessions, such as journaling to identify negative thoughts or practicing new skills to overcome your anxiety.

What Does CBT Stand For And What Can It Help?

CBT Is An Excellent Form Of Therapy That Treats Depression And Anxiety

Cognitive behavioral therapy, or CBT, is one of the most popular forms of psychotherapy, helpful for treating numerous mental health issues. It’s an evidence-based treatment, and plenty of research has supported its success.

The term therapy gets used a lot, but many people don’t fully understand its scope. It’s not a «one size fits all» approach. So, while CBT may have worked well for your friend, it might not give you the same results. This is why it’s imperative to work with your therapist to ensure you are getting the right form of treatment. Just as you should trust your doctor to properly diagnose and treat a physical condition, it’s important to allow your therapist to recommend the best therapy. After all, this is the expert you are going to for help. You can express your interest in CBT, but be open to other forms of therapy if your therapist does not believe CBT is right for you.

How CBT Works

The process behind CBT is that our thoughts affect our feelings, which affect our behaviors. For example, you may think if you go to a party, everyone will ignore you, so you feel anxious and defeated, and thus decide you will not go to the party. This formula is essential because some therapies start by focusing on feelings rather than thoughts and might work to help a client feel less anxious first. Proponents of CBT, therefore, believe that CBT is more effective because it is straightforward and can be taught easily to most clients. It is easier to state thought and examine it than it is to try to explore a feeling. And with chronic depression, it’s imperative to identify and examine all the thoughts that are part of the depression, as there is likely not going to be just one.

CBT aims to break the link between cognition (the thinking processes) and behavior (action following thoughts and feelings) when under mental stress. CBT is a type of psychotherapy which focuses the client on the connection of thoughts, emotions, and behaviors. CBT works to help clients monitor and understand the thoughts they have, which then creates the feelings and behaviors they find uncomfortable or problematic.

What Does CBT Treat?

Cognitive behavior therapy has been used successfully to treat depression, anxiety, obsessive-compulsive disorder (OCD), panic disorder, post-traumatic stress disorder (PTSD), various phobias, eating disorders, sleep problems, and substance abuse. CBT has also been shown to help people with medical conditions like irritable bowel syndrome, chronic fatigue syndrome, and chronic pain conditions. In these cases, CBT helps clients change irrational or unhealthy thoughts to rational, healthy ones, which therefore reduces negative feelings and increases positive behaviors.

Continuing with the example above, the client is able to say, «There is no reason to believe that everyone will ignore me. If for some reason I feel like I am being left out, I can talk to my friend Rachel since I know she will be there. I can do this.» At that point, the client is going to feel less anxious and defeated and is more likely to attend the event. In other words, CBT helps people change patterns of thought to produce new emotions and different behaviors.

Is CBT Effective?

The simple answer is yes, it is effective. Many people choose between CBT, medication, or a combination of the two. This is something that depends on your unique situation and the advice of your doctor and therapist. CBT has been shown to be an effective treatment with and without medication.

The more complicated answer to CBT’s effectiveness depends on a variety of factors. The client has to work on the skills their therapist teaches them all week, not just in session. This requires commitment from the client to examine and challenge thoughts continuously. The client has to believe it can work for them and be willing to explore changes. The client also must have some patience. It takes time to change thought patterns. If you go into CBT expecting significant success after one or two sessions, you are likely to be frustrated. Finding out if CBT is right for you, opposed to other forms of therapy, involves talking with someone with proper training in CBT for an evaluation and then getting started with the work.

What Does CBT Involve?

Different therapists may proceed differently using CBT, often depending on the needs of the patient. CBT is typically introduced with an explanation of the process, the length of time that may be necessary for treatment, and a full exploration of underlying thoughts that may be causing the presenting problem. CBT incorporates the use of homework to record feelings and thoughts, journaling, relaxation techniques, learned coping skills, and in some cases, mindfulness. The basis of CBT is that there are common cognitive distortions (the negative thoughts) that lead to negative feelings and behaviors, and these distortions must be challenged. A common one is called magnification, where the individual has a negative event occur, and it feels insurmountable instead of being viewed as a single event and a solvable problem.

There are many different exercises your therapist may teach you on how to challenge these thoughts. It may be writing down the idea and looking at the evidence. Is there any information that supports this negative thought? Is there evidence that disproves the negative thought? If the worst thing happens, then what? The purpose is to take the power of these overwhelming feelings and learn to view problems as solvable. There are many other exercises your therapist can share with you. As mentioned before, CBT as a whole is not a one size fits all, and neither are the various techniques and exercises that are part of CBT.

Choosing A CBT Therapist

When selecting a CBT provider, you should look for a licensed therapist who has practical experience and training with CBT techniques. It’s also a good idea to find a therapist who has experience using CBT with your specific problem or issue, such as anxiety or depression. You can ask potential therapists about their training and experience with CBT and what issues they work with most successfully.

If you’re unable to locate a therapist who offers CBT in your area, BetterHelp is an online therapy platform that hosts thousands of therapists who utilize CBT in video, phone, and chat sessions.

Online cognitive behavioral therapy has been found to be at least just as effective as face-to-face therapy. In fact, a University of Zurich study found it to be more effective in the medium and long-term than in-person therapy, with just no more depression able to be detected in 57% of clients at 3 months post-treatment, compared to just 42% of in-person therapy users. Another study, which actually reviewed 373 studies of internet-based cognitive behavioral therapy (ICBT), found it to be particularly effective in treating mental health conditions like depression, general or severe anxiety, social anxiety, PTSD, mood disorders, and other conditions that can make it difficult to get to in-person sessions.

What’s more, BetterHelp tends to be cheaper than traditional in-person therapy. This is because you don’t have to commute or pay for transportation to get to and from sessions, and our therapists don’t have to pay to rent out office space. Additionally, sessions can be conducted anytime, anywhere, via a variety of mediums – phone call, video chat, instant messaging/texting, or live voice recording can all be used. Continue reading below to find reviews of some of our licensed mental health professionals, from people benefitting from online cognitive behavioral therapy.

Counselor Reviews

«Dr. Kapil has been marvelous in helping me organize my thoughts for better outcomes and growth through CBT. She is great with her follow-up (even when I’m not so great at replying). Highly recommend!»

Conclusion

Hopefully, by reading this article, you now have a better understanding of what CBT is and how it works. By finding a therapist, you can change your negative thought patterns into ones that are positive, and start having a happier and healthier mindset and lifestyle. Take the first step today.

Commonly Asked Questions On This Topic:

What is CBT and how does it work?

CBT is an abbreviation word that may mean compulsory basic training, competency based training, or cognitive behavioral therapy depending on the context. In psychology, the word CBT refers to cognitive behavioral therapy. CBT is widely used to treat a variety of mental health conditions, such as depression, anxiety, substance use disorders, and eating disorders. The focus of CBT is to examine how an individual’s thoughts and feelings influence their behaviors. Through sessions with a CBT therapist, a person can work towards changing their unhelpful patterns of thinking and behavior, and developing healthy coping strategies.

What is the main purpose of CBT?

The core principles of CBT are that unhelpful patterns of thinking and behavior contribute to psychological distress. CBT therapists help individuals identify distorted thinking and unhelpful behavior, and move towards healthier thinking and behavior patterns. Research has revealed CBT to be very effective for improving quality of life for individuals living with mental disorders.

For more information about cognitive behavioral therapy, visit the American Psychological Association’s site.

What is CBT?

If you think of yourself as uninteresting, unintelligent, and unworthy of anything good, you’re probably not going to put yourself out there very much. In fact, you’re likely going to miss out on a lot of connections and opportunities throughout your life.

But what if your negative thoughts are just like any other bad habit that can be broken? According to cognitive behavioral therapy (CBT), that’s just what they are.

True to its name, Cognitive behavioral therapy (CBT) is a combination of cognitive and behavioral therapies that explores how your thoughts (cognitive) and actions (behavioral) intertwine to impact the way you feel and experience your life.

In other words, negative thoughts cause self-destructive feelings and behaviors. So if you think you don’t deserve to be happy or you’ll never amount to anything, you’re not going to even try to reach your goals. On the flip side, unhealthy and self-destructive behaviors also lead to negative thoughts and feelings. So when you don’t change out of your pajamas or get out of bed most days, you may start to feel sluggish, incapable, and useless.

CBT is the most researched form of psychotherapy. It takes a practical, structured, skills-based approach that’s often short-term and focused.

As the client, you’ll be actively engaged in the process both during the session and between sessions, with homework assignments, real-world practice, and self-reflection.

CBT is based on a few core principles which include

How does CBT work?

The idea behind CBT is that it is possible to have some control over your thoughts, feelings, and behaviors.

What follows is that as you unlearn negative automatic thoughts and deeply held core beliefs and replace them with helpful or productive thoughts and beliefs, you can radically change your experience of life. And as you replace harmful coping behaviors with healthier activities, you’ll feel better and be more equipped to cope with life’s challenges.

As you unlearn negative automatic thoughts and deeply held core beliefs and replace them with helpful or productive thoughts and beliefs, you can radically change your experience of life.

One of the first steps in CBT usually involves developing an awareness of this thought-feeling-behavior interconnection so you can identify new ways of responding that better support your goals.

In therapy, you’ll focus on changing both thoughts and behaviors using multiple skill-based strategies including

Not every CBT therapist will use all of these strategies. It’s a collaborative process that depends on your treatment goals, preferences, and specific situation.

The aim of these practices is to

What is a thought record?

Thought records are a common CBT technique that allows you to take a closer look at the messaging you’re giving yourself, notice when you’re ruminating, and practice making impactful shifts in your perspective.

Completing a thought record typically includes five steps

For example, if you’re terrified that you’re going to fail an upcoming exam, you might notice the automatic thought, “I’m a failure” that’s attached to a deeply held core belief, “I’ll never amount to anything.”

Using a thought record, you can begin to notice how these thoughts make you feel and challenge them by listing evidence to the contrary and exploring potential alternative positive thoughts.

As you challenge the “failure” thought, you might say, “this is a really tough test (self-compassion). My plan is to study for 30 minutes every morning and evening (plan of action). I’ll learn the materials as much as I can, and I’ll do my best. When my fear of failing overcomes me, it doesn’t help me pass the exam. In fact, it gets in the way of me doing what I need to do to succeed. I’m going to stop listening to that thought today.”

A note about CBT and medication

CBT can be used on its own or in combination with medication, which sometimes produces the strongest results. There is not enough research to say whether cognitive behavioral therapy, medication, or another form of treatment works better for many mental health disorders. Much of it depends on your specific situation and preferences.

What to expect during a CBT session

The focus of CBT is on the present so you typically won’t dive into early childhood experiences, analyze dreams, or go deep into the issues that lead up to your current situation.

CBT is usually broken up into phases including assessment, the middle phase, and the ending phase.

In general, your therapist will

What conditions does CBT treat?

CBT can be used to treat a range of mental health issues for children and adults including:

When not to use CBT

While each person and set of circumstances is unique, there are a few cases where CBT generally is not considered an appropriate treatment including

Potential benefits and disadvantages of CBT

Cognitive behavioral therapy has the potential to change the way you think, feel, and act in response to the particular struggles that you’re facing, which can be profoundly impactful.

While it can’t change the world around you, it can support you in changing the ways that you experience it. In cognitive-behavioral therapy, your therapist will work with you to become more aware of your harmful patterns and support you in replacing them with healthier and more positive habits and ways of thinking.

While CBT can’t change the world around you, it can support you in changing the ways that you experience it.

Potential benefits include the opportunity to

Disadvantages

While CBT has been shown to be effective for many mental health disorders, it’s not for everyone.

In general, psychotherapy can cause you to feel more upset or uncomfortable during the process. If this happens to you, it’s important to discuss your experience with your therapist.

Additional drawbacks of CBT may include:

How long does CBT take to work?

Cognitive behavioral therapy tends to be one of the shorter forms of therapy that generally takes place over 10 to 20 sessions.

This doesn’t mean that you’ll experience results immediately. Changing your long-standing thinking patterns and deeply-rooted habitual responses will usually take time. The good news is, many people notice incremental positive changes with CBT which can happen in a relatively short period of time.

CBT can be done online

If you’re leaning towards trying CBT after considering some of the different forms of psychotherapy, you can connect with a therapist from the comfort of your own private space.

CBT can be done in person or via teletherapy (online), and more research over the last year and a half of the pandemic is telling us that online therapy is a powerful and effective pathway for more people to connect to mental health services and support that they need.

What is CBT?

Cognitive Behavioral Therapy (CBT) is an effective form of psychological treatment that is practiced by many thousands of therapists worldwide. CBT theory suggests that our thoughts, emotions, body sensations, and behavior are all connected, and that what we think and do affects the way we feel. Thousands of research trials have demonstrated that CBT is an effective treatment for conditions from anxiety and depression to pain and insomnia. It is helpful across the lifespan – children, adolescents, adults, and older adults can all benefit. CBT is flexible too – it has been proven to be effective in face-to-face, online, and self-help formats.

The basics of CBT

There are many different types of psychological therapy and each is grounded in its own theory and assumptions about how people ‘work’. There are a number of key insights in the cognitive behavioral therapy model which help to distinguish it from other therapies. These ideas are the foundations upon which cognitive behavioral understandings and treatments have been built. Some definitions of CBT can help to clarify what makes it unique.

Cognitive behavioral therapies, or CBT, are a range of talking therapies based on the theory that thoughts, feelings, what we do and how our body feels are all connected. If we change one of these, we can alter the others. When people feel worried or distressed, we often fall into patterns of thinking and responding which can worsen how we feel. CBT works to help us notice and change problematic thinking styles or behavior patterns so we can feel better. CBT has lots of strategies that can help you in the here and now. British Association For Behavioural & Cognitive Psychotherapies

Cognitive Behavior Therapy (CBT) is a time-sensitive, structured, present-oriented psychotherapy that helps individuals identify goals that are most important to them and overcome obstacles that get in the way. CBT is based on the cognitive model: the way that individuals perceive a situation is more closely connected to their reaction than the situation itself. Beck Institute

Cognitive behavioral therapy (CBT) helps people identify and change thinking and behavior patterns that are harmful or ineffective, replacing them with more accurate thoughts and functional behaviors, It can help a person focus on current problems and how to solve them. It often involves practicing new skills in the “real world”. American Psychiatric Association

CBT is about meanings

CBT is fundamentally about the meanings which people make of their experiences. CBT is often misrepresented as being concerned with ‘fixing’ faulty thought processes, being ‘rational’, or only working with ‘surface’ issues: but all of these are mischaracterizations. As we live our lives we interpret what is going on around us: we form beliefs and understandings. These meanings affect how we actually perceive the world. Sometimes our beliefs are distressing to us and can lead to unhelpful ways of acting. The role of a CBT therapist is to help their clients to understand and examine their beliefs: to help them to make sense of meanings. Tamara suffered from obsessive compulsive disorder (OCD) and is a good example of how CBT can be used to unravel meanings.

Shortly after Tamara had her first child she began to experience unwanted intrusive thoughts about harming her baby. She took this to mean that she was a bad and dangerous person. She felt terribly ashamed and frightened, tried to push the thoughts away, and made her partner do most of the childcare in case she caused harm to her baby. Tamara eventually summoned the courage to tell her therapist about the thoughts she had been having. Her therapist helped her to understand that intrusive thoughts are extremely common and entirely normal. Over time Tamara came to understand that her thoughts were precisely the sort that a person who really cared about her baby and felt responsible for it’s safety would have – a truly bad and dangerous person would not worry like she did about the baby’s wellbeing. This change in perspective really helped Tamara. She no longer felt frightened to care for her son and was able to enjoy being a mother.

Appraisals matter

The insight of the CBT model is that it is not events that bother us. Instead, it is the way that we interpret events – the meaning that we give to them – that gives rise to our feelings. This explains why two people experiencing the same event can react in completely different ways. Let’s consider an example:

Figure: How we interpret events determines how we feel about them.

The first interpretation personalizes the events (“What have I done wrong?”) and results in feelings of anxiety. The second interpretation understands the friend’s behavior in more neutral terms and leads to a different outcome.

Figure: Another example of how interpreting events determines how we feel about them.

The first interpretation here is an excited one – the offer of a promotion is viewed as a welcome opportunity. The second interpretation is less positive – the person offered a promotion is making a catastrophic prediction about what is likely to happen and the result is anxiety.

This idea about how our interpretation of events matters is not new. Nearly 2000 years ago the Greek philosopher Epictetus said:

“Men are disturbed, not by things, but by the principles and notions which they form concerning things.” Epictetus [1]

Shakespeare said something similar in 1602:

“There is nothing either good or bad but thinking makes it so.” Shakespeare [2]

It may not be a new idea, but it is a powerful one. It explains why some people are pleased when given the opportunity to sing in front of a crowd (“At last, my talent will be recognized!”) when other people would be terrified at the prospect (“I will make a fool of myself and everyone will laugh at me!”). It can explain why some people often feel very anxious (perhaps they have a habit of interpreting situations as threatening) or very sad (perhaps they have a habit of interpreting situations very negatively).

It’s a hopeful idea too: although we may not always be able to change the situations in which we find ourselves (or the people we meet), we are in charge of how we interpret events. The attitude we bring to a situation, and the perspective we choose to take, determines how we feel. Viktor Frankl, a survivor of the Nazi death camps, said this most powerfully:

“Everything can be taken from a man but one thing: the last of the human freedoms – to choose one’s attitude in any given set of circumstances, to choose one’s own way.” Frankl [3]

Thoughts, feelings, body sensations, and behavior are connected

Another important part of cognitive behavioral theory is that our thoughts, feelings, body sensations, and behavior are all inter-related and can affect one another. Things that we do (or things that happen to us) can affect what we think, which can in turn affect how we feel. If you have ever felt poorly with an illness, then you might have had the experience where your body feelings and emotions made you see the world in a ‘bleaker’ or more ‘catastrophic’ light. CBT therapists have lots of ways of representing the relationships between our attention, perception, thoughts, feelings, and behavior. One traditional way of representing how thoughts, feelings, and behavior interact is with a ‘hot cross bun’ diagram [4].

A more helpful way of representing the relationships – one which explicitly captures meanings – is with a cognitive appraisal model.

Figure: We can use a cognitive appraisal model to represent the importance of meanings in the perpetuation of distress.

The inter-relatedness of thoughts, emotions, body sensations, and behaviors can lead to problems:

The inter-relatedness works to the advantage of the CBT therapist though. If these nodes are inter-related, it means that making a change in one area can cascade into changes in other areas. For example, people who experience panic attacks often interpret normal body sensations in catastrophic ways. These ‘mistakes’ in interpretation lead to powerful and rapidly escalating feelings of anxiety. Cognitive behavioral treatment for panic involves ‘correcting’ these thinking errors, which results in downstream changes in emotion and behavior.

People think on different levels

Cognitive behavioral therapy recognizes that human beings think on different levels: we say that people have different levels of cognition [5]. Cognitive behavioral therapists will help their patients to examine their thinking at all of these levels and will choose therapy techniques which target the most appropriate level.

The level closest to the surface are automatic thoughts. These are thoughts or images which involuntarily ‘pop’ into our minds. They often appear in response to a trigger which can be an event, feeling, or another thought or memory. Automatic thoughts can be accurate (in which case CBT therapists would tend to leave them alone), or they can be biased (in which case they may merit further discussion). Some examples of automatic thoughts include:

The deepest level of cognitions are our core beliefs. These are often unspoken and may never have been verbalized. We often hold core beliefs as ‘truths’ about ourselves, the world, or other people, but it is important to remember that they are opinions and not facts. We are not born with them, but rather they are the product of our life experiences. They can be thought of as our implicit answers to the question “What has life taught you [about yourself, other people, or the world]?”. Core beliefs often take the form of ‘absolute’ statements. Examples of some negative core beliefs include:

The middle level of cognitions are intermediate beliefs, which often take the form of rules and assumptions. These can often be phrased in the form of “If… then” statements or contain the tell-tale words ‘should’ or ‘must’. We may hold on to our rules or assumptions as ways of preventing the worst consequences of our core beliefs from coming true. Examples of rules and assumptions include:

It is important to recognize that cognitions at different levels interact: the kinds of automatic thoughts that we have are often determined by the kinds of core beliefs that we hold (in fact, therapists often look for patterns in automatic thoughts in order to take educated guesses about what core beliefs their patient holds). For example, when confronted with an ambiguous situation where they may have been let down by a friend, the person who holds the core belief “I am unlovable” is more likely to have an automatic thought “I don’t matter to them”. Similarly, when confronted with an ambiguous situation where other people might give good or bad feedback, the person who holds the core beliefs “I’m stupid” and “Other people are critical” is more likely to have the automatic thoughts (predictions in this case) “They’ll think I’m an idiot” and “They’ll make my life hell”. Cognitions at any of the levels can be more or less helpful – CBT therapists will be looking to identify thoughts, beliefs, or rules that are potentially self-defeating.

Thinking can be biased

Cognitive behavioral therapy recognizes that any of our thoughts, beliefs, or rules can be more or less accurate ways of perceiving the world. A thought can be positive “I did well” or negative “I did badly”, but this is less important than whether it is accurate or inaccurate. Despite what we might prefer, it is unavoidable that bad things will happen to all of us. Trying to avoid every negative event, thought, or emotion is a losing battle and would in any case be counterproductive. More important is that our thinking can be inaccurate. And because our feelings are influenced by the way we think, we often experience negative emotions because we believe inaccurate things – it is as though we feel bad because we are lying to ourselves! Thoughts can become biased for many reasons:

People’s thinking becomes biased in characteristic ways. In Beck’s early work on depression he recognized that “even in mild phases of depression, systematic deviations from realistic and logical thinking occur” [6]. Four of the ‘cognitive distortions’ that Beck identified early on included:

Arbitrary interpretation which describes the process of “forming an interpretation of a situation, event, or experience when there is no factual evidence to support the conclusion or when the conclusion is contrary to the evidence”. An example of arbitrary interpretation would be having an interaction with a shopkeeper and having the thought “they think I’m worthless”.

Selective abstraction which describes the process of “focusing on detail taken out of context, ignoring other more salient features of the situation, and conceptualizing the whole experience on the basis of this element”. An example of selective abstraction would be receiving a ‘B+’ grade on a piece of schoolwork, paying particular attention to a comment about how it could be improved, and thinking “I did badly”.

Overgeneralization describes individual’s patterns of “drawing a general conclusion about their ability, performance, or worth on the basis of a single incident”. An example of overgeneralization would be a father noticing their three-year-old child pushing another child in the playground and thinking to himself “I’m a poor parent because he’s a rude child”

Magnification and minimization describe “errors in evaluation which are so gross as to constitute distortions … manifested by underestimation of the individual’s performance, achievement, or ability, and inflation of the magnitude of his problems and tasks … It was frequently observed that the patients’ initial reaction to an unpleasant event was to regard it as a catastrophe”. An example of magnification would be receiving a telephone call from a friend to say they will be late to a meet-up and thinking “well, the evening is ruined”.

To learn more about the ways in which people’s thinking can become biased read our Psychology Tools guide to unhelpful thinking styles.

Things that we do can have unintended consequences

The physicist Isaac Newton’s third law of motion states that “Every action has an equal and opposite reaction” [7]. Our actions are similar – everything that we do has a consequence. Some consequences are intended, but others are not. A common step in CBT is to ask the question “What were the consequences of acting that way?”. You might have escaped a frightening situation with the (intended) consequence that you felt safer. But perhaps some unintended consequences were that you learned that it feels good to escape and escaping became your ‘go to’ strategy for handling tricky situations. Therapists who use CBT are trained to pay particular attention to any sequences that appear to get stuck in a loop or jammed (where an action feeds back to cause more of the problem).

Figure: Our actions have intended and unintended consequences.

For example, if you suffer from depression you might spend much of the time feeling sad, low, and demotivated. When you feel that way it is difficult to do the things that used to give you pleasure, and so you might avoid situations with the intended consequence of conserving your energy. Unfortunately, the unintended consequence of behaving this way is that you have fewer opportunities for good things to happen to you, and the result is that you stay depressed.

CBT is a ‘doing therapy’

CBT is a great way of understanding of what is keeping a problem going and when we are armed with that information our job is to take action in order to get it ‘unstuck’. What makes CBT different is that it is not just a ‘talking therapy’. Psychologists have found that to be really helpful, a therapy has to help you to make changes in your life and so it is better to think of CBT as a ‘doing therapy’. CBT therapists can choose from a huge range of strategies and techniques to promote change. Some of the most common CBT strategies for change are:

CBT works

What is CBT used for?

CBT was originally developed by Aaron Beck as a treatment for depression, but it was quickly adapted to treat a wide range of mental health conditions. Emotional problems that CBT is used to treat include:

How effective is CBT?

CBT is an evidence-based form of therapy which means that researchers try to discover what components of therapy work, for which problems, and why. Individual therapy sessions also pay close attention to evidence: clients in CBT are typically encouraged to set personal goals (e.g. “If I was feeling less anxious I would be able to do my shopping by myself without needing to escape”) and then record data (evidence) about whether these goals are being met.

When we ask “how effective is CBT?” we really mean “what is it effective for?” and “effective compared to what?” We also need to consider “how often do these conditions get better by themselves?”. One way that researchers address these questions is by conducting randomized controlled trials (RCTs), where different treatments are carefully and systematically compared to one another. The same process is used in medicine to test the safety and effectiveness of new drugs. Over the past few decades thousands of such studies have examined CBT and researchers can now combine the results of these RCTs into ‘meta-analyses’ to show, in even more reliable ways, which treatments work. The graph below shows the result of a meta-analysis of CBT that was published in 2015 [8]. The results are from 48 studies that compared CBT with ‘treatment as usual’ for nearly 7000 people with anxiety, depression, or mixed anxiety & depression. The results show a clear effect in favour of CBT – more people get better when they receive CBT compared with their usual treatment.

Figure: The effectiveness of CBT vs treatment as usual (TAU).

Another way to measure how effective CBT is for treating psychological problems is to look at ‘response rates’. Somebody is said to ‘respond’ to a therapy if their symptoms have improved significantly by the end of treatment. A study that compared 106 meta-analyses was published in 2012 [9]. The graph below shows the response rates for CBT across a wide variety of conditions.

Figure: Response rates for CBT for a variety of conditions (higher is better).

These results look good, but you might be thinking “What do the results look like for the alternatives?” Where adequate data were available, that same study also compared the response rates of CBT to other ‘genuine’ forms of therapy or treatment as usual. CBT for depression was at least as effective as medication or other forms of psychotherapy, and more effective than treatment as usual. CBT for anxiety was typically superior to other forms of genuine and placebo therapies and was judged to be a “reliable first-line approach for treatment of this class of disorders”.

Figure: Response rates for CBT compared to other treatments, or treatment as usual.

The message from these reviews is that for many conditions CBT is as effective or more effective than other genuine forms of therapy and is typically better than ‘treatment as usual’ (which often includes medication or check-ups with doctors) or doing nothing. In recognition of its effectiveness there has been a nationwide push by government in the United Kingdom to make CBT therapies available for free to everyone who needs them.

The history (and future) of CBT

What came before CBT?

To really understand the cognitive behavioral therapy (CBT) approach we need to know where it came from and what it was developed in reaction to. CBT emerged in the 1960’s, in an era when psychological therapies were much less established than they are today. Radical new ideas and theories about psychological functioning were emerging and there was much less evidence for the effectiveness of each approach. This meant that therapists were experimenting with new techniques. The dominant models at the time were psychoanalysis and behaviorism.

The clinical practice of psychoanalytic psychotherapy was established by Sigmund Freud in the late nineteenth century. Psychoanalysis, and a shorter variant called psychodynamic psychotherapy, are still practiced today. The central proposal of psychoanalytic theory is that we have a dynamic unconscious whereby much of our mental life occurs outside our conscious awareness. Psychoanalysis proposes that some of our thoughts and feelings are kept outside of our awareness by our ‘defenses’ but can still affect our behaviors, attitudes and experiences – which can lead to problems. Resolution is said to come from bringing these difficult thoughts and feelings into our conscious awareness. Perhaps the aspect of psychoanalytic theory that has gained the most traction concerns how peoples’ early relationships with caregivers (their attachment relationships) affect how they form relationships for the rest of their lives. ‘Attachment theory’ is the foundation of many modern approaches to psychotherapy. Psychoanalysis has been criticised on the grounds that many of its claims cannot be tested and that they are not falsifiable. Nevertheless, psychoanalysis and psychodynamic psychotherapy are still practiced today despite no longer being the dominant model in mental healthcare.

Behaviorism is an approach grounded in the scientific study of learning and behavior. Compared to psychoanalysis its practice is much more empirical, experimental, and scientifically robust. Early behaviorist researchers including John Watson and Ivan Pavlov discovered the concept of classical conditioning and other ideas about how animals and humans learn. B. F. Skinner is famous for his discovery of operant conditioning – the idea that our behavior can be shaped by contingencies (what comes before and after). An important part of these psychologists’ research explored how fears are learned. These ideas were applied clinically as ‘behavior therapy’ by luminaries including Joseph Wolpe and became the foundation of fear reduction techniques that are still in use today. Behavior therapy led to great progress in the treatment of anxiety disorders and these concepts are still applied today, but therapists found that it had less to offer in the treatment of conditions such as depression and psychosis.

Who developed CBT?

Aaron T. Beck is responsible for the development of the form of CBT that is most commonly practiced today. No history of CBT is complete without mention of Albert Ellis who was also developing a form of cognitive therapy at the same time as Beck. Ellis’ work became Rational Emotive Behavior Therapy (REBT) and shares many similarities with CBT.

Figure: Aaron T. Beck developed cognitive therapy.

Aaron Beck was a psychiatrist who was working at the University of Pennsylvania in the 1960’s. He had been trained in psychoanalysis but became disillusioned with the approach of using free association and began to experiment with more direct techniques. Working with depressed clients he found that they experienced streams of negative thoughts which he called ‘automatic thoughts’. He found that he could work effectively with his client’s thoughts and beliefs – the meanings that they created as they came to understand the world around them. He published the seminal Cognitive therapy and the emotional disorders in 1975 and has since authored or co-authored 25 books and over 600 articles.

Simultaneously, Albert Ellis was working on a form of cognitive therapy descended from the Stoic idea that it is not events that distress us but the meaning we give to them. Ellis’ ideas were developed as Rational Emotive Behavior Therapy (REBT). There is significant overlap between both approaches but it is arguably Beckian cognitive therapy that has been more influential.

What types of CBT are there?

CBT has an empirical stance which means that it has changed and developed with the emergence of new scientific discoveries and theoretical advances. Many clinicians and researchers trained with Beck and Ellis and have since gone on to train subsequent generations of therapists, scientists, and scientist-practitioners. Over time CBT has grown to encompass a wide variety of therapeutic practice and modern CBT is best thought of as a ‘family’ of therapies that adapts as scientists make new discoveries about how people ‘work’.

Figure: The history and future of CBT. A timeline of what came before and after Beck and Ellis’ cognitive behavioral therapy.

What is CBT like?

Therapists who practise psychological therapies are trained to focus on particular aspects of a person’s experience and to react in particular ways. We can say that every therapy has a different ‘stance’. For example, systemic therapists are trained to focus on the way people relate to one another and on how an individual responds to the actions of other people in their network. Solution-focused therapists’ training leads them to help their clients to stay focused on the future and on potential solutions to current difficulties. Psychodynamic therapists are trained to notice how patterns from early (attachment) relationships are played out in a person’s later relationships. Some important properties of CBT’s stance are that:

What is CBT like? The process of treatment in cognitive behavioral therapy

A helpful way to illustrate how CBT works is to walk through the steps that a therapist might go through with a client. In face-to-face CBT a therapist may go through some or all of the following stages. Remember that although the process is described here in a linear fashion people and their problems are not straightforward and there is often a ‘dance’ back and forth between the stages.

Stage 1: Assessment in cognitive behavioral therapy

During the first session (commonly the first few sessions) a cognitive behavioral therapist wants to find out what kind of problems are troubling their client. They will also want to explore the client’s goals – what would they want to be different by the end of therapy? CBT therapists will conduct an assessment by discussing some or all of the following:

CBT assessment technique 1: Focus on specific events that happened recently

To understand their client’s problems, therapists who practice cognitive behavioral therapy often begin by paying close attention to specific events that have happened relatively recently. This means that they attempt to identify specific details like “Yesterday when I saw someone who looked like my attacker I was frozen to the spot with terror” rather than “I’m just always feeling so low that I’m not sure it’s worth it anymore”. It can take some work to extract specifics from examples like the latter: when the therapist asked for some more details she was told “When I watched a programme last night on tv about friendships and realized I didn’t have anyone close anymore I felt so sad that I wondered what the point was in my existing”.

The reason that CBT focuses on specific events is because our lives are made up of specific moments all chained together. We live our lives moment-by-moment and feel our feelings that way too. We might tell ourselves stories like “I had the most boring day ever” but chances are that your day was made up of some boring moments, and perhaps some mildly interesting ones too. If we want to pay attention to our thoughts and behaviors, these happen moment-by-moment and we will miss important parts if we gloss over the details.

The reason that CBT focuses on things that are problems now is because problems that happened in the past may no longer be a problem. Even if terrible things did happen in the past, our suffering – what we want to relieve – happens in the present. One of the assumptions that CBT makes is that things happening in the here-and-now (perhaps thoughts, perhaps action) are contributing to that suffering. A final advantage of working on current material is that our memory for it is often better, which means that we can explore it in more detail.

CBT assessment technique 2: Break moments down into helpful components

Once we have identified a specific and relatively recent event, the next job is to break it down into manageable parts. These might include:

The reason that CBT therapists conduct assessments by breaking events down into components is because a cognitive behavioral approach recognizes that these components are interconnected. One component affects other components in understandable ways. Making sense of these connections is called case conceptualization which we will explore in the next section. Some of the most helpful CBT worksheets and information handouts for psychological assessment include:

Stage 2. Case formulation (case conceptualization) in cognitive behavioral therapy (CBT)

It’s one thing to identify a problem but in order to find solutions we need to (1) understand what is keeping the problem going and (2) find some ways to stop it. CBT therapists use a process called ‘case conceptualization’ or ‘case formulation’ to come to an understanding of how a problem operates. A formulation is simply a model or set of hypotheses (educated guesses) about what is going on: an idea about how the pieces fit together. A therapist will form their own hypotheses about what is going on, will share hypotheses with their client, will explore any hypotheses the client has, and will try to find ways with the client of testing whether these hypotheses are accurate. CBT therapists will often draw a case formulation diagram together with their client as a way of ensuring sharing their understanding of what might be happening.

CBT focuses on relationships and consequences

When considering any problem, the therapist will try to gather information about: where and when a problem happens; what kinds of things trigger it; and what thoughts, emotions, body sensations, and behaviors it leads to. The next step is to look for relationships between these components. This is helpful for working out what happened and in what order. As a general rule:

CBT focuses on what keeps a problem going

A fire needs three things to start: heat, fuel, and oxygen. As long as those things are present the fire will keep on burning. We say that a fire’s maintaining factors are heat, fuel, and oxygen. With this knowledge, firefighters can choose which maintaining factor to target. Depending on the type of fire they are faced with they may decide to:

CBT examines problems in a similar way: the focus is on maintaining factors. Like a fire it’s not so important to know what started it, but we do need to know what is keeping it going. Therapists who use CBT are trained to pay particular attention to any sequences that appear to get stuck in a loop or jammed (where an action feeds back to cause more of the problem). There are many different ways that human problems can be maintained. Some of the most common maintaining factors that can keep our problems stuck include:

How the pieces fit together: how problems persist

Psychologists have found that maintaining factors often join together in ‘typical’ ways to cause problems. In this section we will look at some common problems and explore the maintaining factors that keep them going.

Anxiety

People who have panic attacks often notice ambiguous body sensations and assume that their presence means something terrible will happen. This way of thinking results in strong emotional reactions followed by understandable attempts to cope. The selective attention, biased thinking, and avoidance are important maintaining factors in panic. These are the areas that CBT treatment for panic will focus on.

Figure: The cycle of panic and the mechanisms that keep it going.

Depression

Similarly, for depression, CBT researchers have found that people with low mood experience changes in thinking and behavior and that these changes can keep the depression going. The diagram below shows how ‘depression mode’ can be maintained in some people.

Figure: One person’s cycle of depression with the mechanisms that keep it going.

Mixed problems

Many people struggle with more than one problem at once and not everyone’s problems fit neatly into models like those above. CBT is flexible though – using the same ‘building blocks’ it provides a framework for understanding problems so that and we can create our own models.

Figure: The building blocks of CBT can help us understand a huge variety of problems.

When Sally came to therapy she was really struggling. She and her therapist took the time to properly understand how she was feeling and identify the things that were maintaining her distress. Using this new understanding Sally, her therapist, and her parents came up with a plan to help her feel better.

Stage 3: Symptom monitoring in cognitive behavioral therapy (CBT)

Once a client and therapist have decided on which problem(s) to target, and have ideas about what might be maintaining the problem, cognitive behavioral therapy (CBT) places great emphasis on monitoring the problems and symptoms. In the same way that thoughts can be biased, our impressions about whether therapy is effective can be biased too. Therapists are especially prone to making assumptions about ‘how well’ therapy is going and can easily be mistaken. This bias can be overcome by regularly measuring symptoms and problems, and ‘checking in’ with clients about whether they think therapy is moving in the right direction. Evidence suggests that therapists who regularly monitor outcomes achieve better results for their clients.

Symptom monitoring can be as simple as counting how often something occurs – such as counting how often someone with panic experiences panic attacks, or counting how often someone with OCD performs one of their compulsions. CBT practitioners also use standardized questionnaires to measure symptom frequency or intensity. There are general measures which might measure anxiety or depression, to specific measures which explore what kinds of thoughts someone is experiencing.

David came to therapy because he was experiencing panic attacks. At the start of therapy his therapist asked him to keep a record of how many panic attacks he was experiencing each week. Then every week they would check in to see what was happening. By the time David completed treatment he was pleased not to have had any panic attacks in the previous three weeks.

Figure: Activity monitoring is one way of linking symptoms to behavior.

Stage 4: Techniques for change in cognitive behavioral therapy (CBT)

Once we have assessed a problem, explored goals, and taken some educated guesses about why the problem is not getting better by itself it is time to take action. Sometimes the case conceptualization stage alone is enough to motivate change: people often feel helped by having spoken about a problem, may feel hopeful when they understand how it is operating, and often spontaneously make changes in their lives (this may explain why people often make ‘early gains’ in CBT treatment). Interventions in CBT are often focused on breaking maintenance cycles – interrupting the vicious cycles that keep problems going. We can separate these into CBT for:

CBT Techniques for changing how you feel by learning something new (psychoeducation)

A crucial cognitive behavioral intervention is ensuring that clients have accurate information. According to the CBT model many problems stem from inaccurate interpretations about the meaning of a situation, trigger, or event. For example, a person with panic disorder may notice their heart racing and mistakenly conclude that they are having a heart attack (this would be a mistake: there are many good and safe reasons why our hearts can beat faster). Or a person with post-traumatic stress disorder (PTSD) may assume that the frightening unwanted memories of their trauma mean that they are going mad (they’re not: it’s very common to have ‘flashbacks’ of traumatic events and there are good neurobiological reasons why this happens). In many cases giving people accurate information about why they are experiencing something is a fantastically powerful intervention.

As well as having conversations with their clients about psychological concepts and principles that they may not be aware of, another way that CBT therapists give their clients new information is with information handouts and CBT worksheets. Some of the most helpful CBT worksheets and information handouts for psychoeducation include:

CBT Techniques for changing how you feel by changing what you think (cognitive restructuring)

An important intervention in CBT is to help clients understand and change unhelpful patterns and types of thinking. One way in which practitioners of cognitive behavioral therapy help their clients to change how they think is by using CBT worksheets to scaffold their thought monitoring and thought modifying practice. There are a huge variety of CBT techniques and resources for helping people to change their thought processes. An essential first step in changing what we are thinking is to identify what is going through our minds – this is called ‘thought monitoring’. Cognitive behavioral therapists use a wide variety of CBT worksheets for thought monitoring. Once clients can reliably identify their negative automatic thoughts the next step is to examine the accuracy and helpfulness of these thoughts – a process called cognitive restructuring. Cognitive behavioral therapists use a wide variety of CBT worksheets for cognitive restructuring. An important type of CBT interventions to help clients consider alternative positions (change what they think) concerns conducting experiments. The classic approach is to conduct a behavioral experiment, of which there are many different variations. We will consider these in more detail in the next section.

CBT Techniques for changing how you feel by changing what you do (or by learning new information)

The final but by no means least important class of CBT interventions concerns changing how you feel by changing what you do. To give you an idea of the importance of this class of interventions it is often said that “CBT is doing therapy not a talking therapy”. The interconnections in the CBT model mean that our actions / behaviors / responses have powerful feedback effects upon our thoughts, emotions, body sensations, and subsequent behaviors. Positive changes in behavior can result in virtuous circles and cascading improvements in cognition and mood. Many of the most powerful CBT interventions involve helping people to confront situations that they are afraid of, or to test the accuracy of some of their most deeply held beliefs by approaching situations without their normal defenses. Behavioral work in CBT often requires confidence and encouragement on the part of the therapist and courage on the part of the client, but behavioral techniques are some of the most powerful available.

Summary

CBT is a powerful and flexible form of psychological therapy. There is a great deal of evidence that it is a helpful approach for a wide variety of problems including anxiety, depression, pain, and trauma. We know that it works when delivered face-to-face and can be effective as self-help. If you would like to access CBT for yourself then take a look at our finding a therapist page. If you would like to try CBT for yourself as self-help then read our Psychology Tools guides to thoughts, emotions, making sense of difficulties, and our guides to common psychological problems, and techniques for overcoming them.

What next?

If CBT sounds interesting to you, then the next step is to carry on working through the Psychology Tools Self-Help section. If you read each chapter and practice the exercises you will learn how to make CBT a useful part of your life. The next chapter is A Guide To Emotions.

References

[1] The Enchiridion of Epictetus

[2] Shakespeare, W. (1996). Hamlet. In T. J. Spencer (Ed.), The new Penguin Shakespeare. London, England: Penguin Books.

[3] Frankl, V. E. (1984). Man’s search for meaning: An introduction to logotherapy. New York: Simon & Schuster.

[4] Padesky, C. A., Mooney, K. A. (1990). Clinical tip: presenting the cognitive model to clients. International Cognitive Therapy Newsletter, 6, 13-14.

[5] Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford press.

[6] Beck, A. T. (1963). Thinking and depression: I. Idiosyncratic content and cognitive distortions. Archives of General Psychiatry, 9(4), 324-333.

[8] Watts, S. E., Turnell, A., Kladnitski, N., Newby, J. M., & Andrews, G. (2015). Treatment-as-usual (TAU) is anything but usual: A meta-analysis of CBT versus TAU for anxiety and depression. Journal of Affective Disorders, 175, 152-167.

[9] Hoffman, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioural therapy: a review of meta-analyses. Cognitive Therapy Research, 36, 427-440.

What Is Cognitive Behavioral Therapy?

Table of Contents

When you feel anxious, scared or stressed, it’s common to have a physical reaction, too. Your heart may pound, your body could tremble or you might bite your nails. Combined, these emotions and involuntary physical reactions can keep you from living a fulfilling life. Cognitive behavioral therapy (CBT) is a psychological treatment that examines your thoughts and actions to help you regain a sense of control.

One of the most studied forms of psychotherapy, CBT can help boost your mood and improve your overall quality of life. Some people who try CBT experience its benefits as soon as their first few sessions. Learn how this form of therapy works, what to expect and how to get started.

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What Is Cognitive Behavioral Therapy?

Cognitive behavioral therapy is a form of psychological treatment that combines two types of therapy: cognitive therapy, which examines the things you think, and behavioral therapy, which examines the things you do. Grounded in understanding the relationship between how you think, feel and act, and how each influences one another, CBT progress is often monitored through journaling and taking a questionnaire prior to or at the beginning of your therapy session to make sure the treatment is effective in leading you closer to the life you want to live. This type of therapy is typically conducted by licensed mental health professionals.

The History of CBT

CBT as we know it today offers a plethora of mental health benefits, and was pioneered by several psychotherapists in the 1960s and 1970s, most notably Aaron Beck and Albert Ellis. Dubbed the “gold-standard of psychotherapy,” CBT is a go-to method for many therapists because it can be helpful in treating a variety of disorders, such as anxiety, attention deficit hyperactivity disorder (ADHD), eating disorders, psychosis, post-traumatic stress disorder (PTSD) and insomnia.

How Cognitive Behavioral Therapy Works

CBT is a popular form of therapy because it’s often a short-term treatment option (sometimes requiring as little as six sessions) that focuses on problem-solving and getting individuals closer to their goals, says Kathleen Camacho, Ph.D., a licensed clinical psychologist and medical psychology instructor at Columbia University Irving Medical Center in New York City. In CBT, there’s an emphasis on teaching coping skills so people can become their own therapists and learn to modify thinking, feelings and behavior.

“In CBT, you learn about the situations that likely prompt distress for you or are most challenging while learning new strategies to cope more effectively,” explains Camacho. “Additionally, you learn how to evaluate your thoughts and physiological symptoms or emotions more objectively rather than taking them at face value.”

The Main Principles of Cognitive Behavioral Therapy

CBT is based on a few core principles, according to the American Psychological Association. Those principles include:

“For example, by helping clients change their behaviors, we not only help clients increase positive emotions, but we can also see a shift in their thoughts from all-or-nothing thinking to more adaptive, realistic thoughts,” says Coniglio.

At its core, CBT proposes that any problems you currently face exist, in part, due to unhelpful thought and behavior patterns. By grounding you in the present, CBT offers a way for you to cope with your problems by intercepting your negative thought and behavior patterns and subsequently reducing the amount of stress you feel.

“Emotions are next to impossible to change directly because they are hardwired in the oldest parts of our brains. So instead, we change thoughts or behaviors in hopes of changing emotions,” says Coniglio. “CBT helps people realize that new behaviors and new ways of thinking can change emotions. This mental shift is not always intuitive at first, but it works.”

Which Therapists Can Practice CBT?

Licensed clinical social workers, certified employee assistance professionals and licensed mental health counselors can all offer CBT. While these credentials reflect their respective years of education or professional training, it’s also important to confirm a therapist is licensed to practice in your state. This can be confirmed with the state licensing board.

Cognitive Behavioral Therapy Can Help Anxiety, Depression, Insomnia and More

CBT can be adapted to treat a wide range of issues, according to the American Psychological Association. Some of these issues include, but are not limited to:

CBT is most suitable for people who want support in developing skills to manage specific problems or better deal with challenging aspects or situations in their lives, such as their relationships, work or school.

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Cognitive Behavioral Therapy Techniques

Since its inception, CBT expanded to serve as an umbrella term encompassing many techniques designed to help with specific issues. Though some are similar, their approaches and applications differ. Here are examples of CBT techniques.

What to Expect From a CBT Session

During an initial discussion with a CBT therapist, the patient gains a sense of how long their treatment will likely be based on:

Each CBT session lasts between 45 and 60 minutes, and a complete treatment can require as few as five sessions and as many as 20 sessions. Ultimately, the length of your treatment depends on how well you stick to the treatment plan, attending sessions regularly and practicing skills during and outside the sessions, says Camacho. A therapist also collaboratively discusses with you how the treatment is going and tailors your treatment based on your progress and revised goals.

What Happens in CBT Sessions

In sessions with therapists like Camacho, you begin by setting an agenda collaboratively, including topics to target during the week. The therapist then reviews how the plan or strategies discussed in the previous session went, often through a weekly self-report questionnaire or by self-monitoring and taking notes outside of therapy. Together, you then evaluate the utility of the skills used or discuss what may have gotten in your way.

“For example, if I’m working with someone who is depressed and they’re struggling to get out of bed and engage in the activities they used to be able to engage in, I may ask if they got out of bed during the week,” says Camacho. “If not, I’ll work with them on setting small goals to help them take steps towards getting out of bed and re-engaging in the world.”

Expect to engage in activities that your therapist considers to be mood-boosting or goal-oriented as well. This component might entail an activity that’s slightly outside your comfort zone.

“With another client who may struggle with social anxiety and worries that during their last interaction they were ‘weird’ and their friend will never want to hang out with them, I may have them face a fear with me in session,” says Camacho. “This technique is known as exposure and, in the circumstance just mentioned, I may have them test their hypothesis—that their friend never wants to hang out with them—by inviting their friend out and then evaluating how what they expected to happen matched up with the outcome.”

At the end of a session, your therapist summarizes what you worked on and encourages or assigns use of the skills and strategies discussed.

CBT via Teletherapy

The rise of teletherapy in recent years drastically amplified the accessibility of CBT. A recent study found internet-delivered CBT works as well as in-person CBT.

“It’s a good option, particularly during the pandemic when people have contended with grief, loss, injustice, changes in schedule, life disruptions and many stressors,” says Camacho. “It’s a way to help individuals cope with the current reality.”

A CBT session conducted online is similar to an in-person session in many ways. With loosened insurance restrictions for telehealth reimbursements, more therapists are now able to see patients for whom travel was a significant barrier to treatment access.

Risks of Cognitive Behavioral Therapy

One common criticism of CBT is that by constantly asking a patient to reframe a bad situation or see things from their perceived aggressor’s point of view, it can make a person doubtful and question whether their perception of reality is valid. But Coniglio notes that a common misconception of CBT is that it’s all about learning to think more positively.

“In fact, if you are experiencing a bad situation and your therapist constantly asks you to reframe your situation in a positive light, it might be time to find a new therapist,” says Coniglio.

Instead, a good CBT therapist helps you think and act in ways that are effective and consistent with your goals so you can be resilient in spite of a bad situation. When a therapist catches you ruminating—thinking or talking about aspects of a bad situation, which can increase negative emotions—they help you shift toward problem-solving and empower you with validation.

Another criticism of CBT is that it requires “too much work.” Some people may struggle with change or find they aren’t motivated to keep a journal to track their thought patterns over time.

“We want to work collaboratively with people to identify the ways in which therapy is or isn’t working while encouraging people to be more motivated for change and acknowledging that they’re doing the best they can,” says Camacho. “Ultimately, we want to set people up for success, so we work on creating smaller, more achievable goals.”

Who Might Benefit From a Different Type of Therapy?

For people whose issues are largely caused or maintained by problematic patterns in their relationships with their partners or loved ones, Dr. Camacho would recommend couples or family therapy.

Meanwhile, those who are more interested in building insight around early life experiences and exploring these in depth to understand how they influenced their patterns of relating or ways of being in the world may want to seek a psychodynamic approach, which poses that your unconscious motives affect your personality, attitude and emotional disorder. Different approaches to psychodynamic therapy will vary based on the issue you want to treat.

Examples of this therapy include Brief Adaptive Psychotherapy (BAP), which treats clients with personality disorders, or Interpersonal Psychotherapy (IPT), which treats clients with depression or substance abuse disorders.

Getting Started With CBT

Several online resources can help point you to a CBT-trained teletherapist or therapist near you. Organizations like the American Psychological Association, the Association for Behavioral and Cognitive Therapies and the Academy of Cognitive Therapy are just a few places to search.

Your employer may offer an Employee Assistance Program (EAP) that includes free and confidential access to therapists who practice CBT. Your insurance company should also be able to provide a list of in-network or out-of-network therapists in your area.

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