When people say therapy, they’re often referring to traditional cognitive behavioral therapy (CBT). CBT is a short-term, goal-oriented treatment that explores the relationship between thoughts, feelings, and behaviors. A CBT therapist helps people change unhealthy or maladaptive behaviors by challenging the thoughts that lead to these emotions and behaviors.
Decades of research confirm the efficacy and effectiveness of CBT. This makes it a popular evidence-based treatment for children, teens, and adults struggling with myriad mental health, behavioral, and emotional issues. During a typical CBT session, the therapist uses logic and data – within an atmosphere of compassion and support – to help clients change their negative thinking patterns. In turn, this leads them to make positive and healthy choices.
The National Alliance on Mental Illness (NAMI) describes CBT this way:
“By exploring patterns of thinking that lead to self-destructive actions and the beliefs that direct these thoughts, people with mental illness can modify their patterns of thinking to improve coping.”
History of CBT
Before CBT, the primary modes of therapy were psychoanalysis and psychodynamic therapy. Developed by Sigmund Freud, the psychoanalytic approach centers on the idea that our past is responsible for our present. Freudian psychoanalysis focuses on a client’s childhood and history, as well as their unconscious and subconscious desires and emotions. In exploring current problems through the lens of the past, psychodynamic therapists help patients understand how their past impacts their present.
Critics of psychoanalytic theory complain the process takes too long. Patients might attend therapy multiple times a week for years on end before seeing any change. The primary role of the therapist was to listen, accept, and reflect.
In contrast, CBT treatment focuses on change and concrete goal setting. It’s a practical, hands-on approach to solving problems.
Psychotherapist Aaron T. Beck is widely credited as the founder of CBT, though Albert Ellis, a colleague, explored similar ideas a decade earlier. Ellis’ work later became rational emotive behavior therapy, or REBT.
Dr. Beck, while studying psychoanalysis, realized that his patients with depression often had long, drawn-out streams of negative thoughts. These thoughts often appeared in their minds automatically. Dr. Beck found that by helping his depressed patients recognize and interrupt these automatic thoughts, they were able to substitute these thoughts with more realistic or helpful ones. In turn, their depressive symptoms decreased.
Beck called his new therapy Cognitive Therapy.
The behavioral part of CBT is rooted in the development of behaviorism in the 1920s. Behavioral therapists during this period included John B. Watson, Joseph Wolpe, Ivan Pavlov, and B.F. Skinner, among others. These researchers made great strides in learning theory and conditioning theory. They showed how behaviors were usually a reflex: a result of reinforcement and/or conditioning to specific cues in a specific environment. Behavior theory assumes that, with the right conditioning, individuals can learn to change any unhealthy behavior.
The merging of Beck and Ellis’ cognitive theories of the 1950s and 1960s with the behavioral theories developed in the 1920s led to CBT as we know it today.
What Does CBT Treat?
Strong evidence backs the practical efficacy of CBT. This makes it a go-to treatment for a wide range of mental health, behavioral, and emotional issues. Research shows CBT is especially helpful for the following issues:
- Anger Management Issues
- Anxiety Disorders (e.g. Panic attacks, panic disorder, OCD)
- Behavioral Issues (e.g. oppositional defiant disorder (ODD), disruptive mood dysregulation disorder (DMDD))
- Borderline Personality Disorder
- Eating disorders
- General Stress
- Psychosomatic Disorders
- Social Skills Deficits
- Substance Use
- Sleep Disorders
This wide range of clinical applications is a big part of why most therapists receive at least some training in CBT. Let’s take a look at some specific things that make CBT so effective.
How Does CBT Work?
CBT’s core dogma is that thoughts lead to behaviors. According to CBT, individuals carry certain beliefs about themselves, others, and the future. This leads them to think automatically in distressing situations. Many of these automatic thoughts are negative, maladaptive, or generally unhelpful.
For example, CBT states that many unhealthy behaviors are rooted in cognitive distortions.
Cognitive distortions may include the following:
- Catastrophizing (making problems bigger than they actually are)
- Overgeneralizing (saying/thinking things like “this always happens to me” when that’s not objectively true)
- Magnification (exaggerating the negative)
- Minimalization (minimizing the positive)
The therapist’s job is to help the client replace these cognitive distortions with more accurate and helpful thinking patterns. In a nutshell, CBT states:
If you think you can’t do something, or if you have certain thoughts that are making you behave in an unhealthy way, change your thoughts to change your desired behavior.
The CBT Process
A CBT therapist first works on getting their client to feel comfortable. After they establish a secure therapeutic relationship, the clinician attempts to understand the problems their client faces. To get to the root of psychological, behavioral, or emotional issues, the therapist and client go through a thorough and comprehensive getting-to-know-you process. Together, they identify the client’s problematic behaviors (or the behaviors that need to change) and determine what thoughts and emotions lead to these actions.
This is the first phase of CBT, known as the assessment.
As part of this assessment, the clinician establishes a baseline to determine the frequency, duration, and intensity of the problem behaviors.
Then the therapist begins comprehensive psychoeducation. They help the client understand how thoughts influence behavior. The therapist illustrates the cyclic nature of thinking, emotions, and behavior. Then, the clinician helps the client substitute maladaptive thinking patterns with more productive ones.
This stage is known as reconceptualization, otherwise known as reframing the problem. Since the therapist works on changing the client’s cognition, this process makes up the cognitive portion of cognitive behavioral therapy.
In order to change the client’s thinking patterns, clinicians utilize a variety of different interventions. For example, many CBT therapists assign thought records or thought logs to their clients. Throughout the week, clients self-monitor their problematic thoughts and behaviors by manually filling out a thought record. The purpose of a written thought record is to get the client to pay attention to damaging or maladaptive thoughts. Most of the time, thought records include a few basic columns, such as Event, Thought, Emotion, and Behavior.
For example, someone with anxiety might fill use their thought record after a stressful driving situation. In this scenario, they might call the event “Driving to work.” The related thought might be “I’m gonna crash.” The associated emotion might be “fear,” and the resulting behavior might be “pulling over to the side of the road.”
During session, the therapist focuses on the first problematic point: the catastrophic thought “I’m gonna to crash.” The clinician works on challenging or testing that belief, and together with the client, comes up with an alternative thought.
Alternative thoughts might include “That car is close, but I’m going to shift slightly to the left,” or “I will remain in control of the car.” The client practices substituting these alternative thoughts throughout the week, each time they find themselves in a similar anxiety-provoking driving scenario.
Other Forms of CBT
Therapists can combine other interventions with traditional CBT, such as relaxation training (RT). In RT, the therapist teaches mindfulness exercises, such as deep-breathing, to calm their client. The clinician asks the client to practice these exercises the next time they find themselves in a stressful situation.
Another intervention used in conjunction with traditional CBT is exposure therapy. Exposure therapy is mainly used to treat anxiety, trauma, obsessive-compulsive disorder (OCD), or specific phobias. It involves gradually exposing the client, in a safe setting, to various scenarios in which they feel fear or anxiety. With time, the client learns to become less sensitive or reactive to the source of their distress.
Relaxation training and exposure therapy are actually types of cognitive behavioral therapy. In addition to being a stand-alone treatment, CBT is often used as an umbrella term for other related therapies and interventions. Other forms of CBT include:
- Cognitive processing therapy (CPT)
- Rational emotive behavior therapy (REBT)
- Eye movement desensitization and reprocessing (EMDR)
- Acceptance and commitment therapy (ACT)
- Self-instructional training (e.g. distraction, imagery, motivational self-talk)
- Dialectical behavior therapy (DBT)
The way therapists use traditional CBT in conjunction with these other techniques depends on the clinical presentation of symptoms.
What’s the Difference Between CBT and DBT?
In recent years, Dialectical Behavior Therapy (DBT) has gained considerable attention from the mental health community. DBT is becoming so popular, in fact, that many wonder how “the new kid on the block” compares to CBT.
There is, in fact, a lot of overlap between DBT and CBT. However, the primary focus of CBT is changing or challenging unhelpful thoughts, while the primary focus of DBT is eliminating harmful behaviors. DBT puts changing behavior first, in the hope that eventually the negative thinking patterns will change as well. While CBT is based on the idea that thoughts impact how you feel and what you do, DBT is based on the idea that emotion dysregulation influences all aspects of your behavior.
Additionally, DBT is rooted in acceptance of thought, while CBT champions changing of thought. For example, if a client constantly thinks “I’m worthless,” CBT challenges this line of thinking as an attempt to get the client to stop behaviors that stem from that thought and its associated patterns of thought.
DBT, however, is less about changing the thought and more about accepting that the thought is just that: a thought. DBT attributes less power to our thinking patterns by proposing that having the thought that I’m worthless is different than actually believing you’re worthless.
In recent years, many CBT clinicians have adopted this concept of acceptance in their therapeutic approach.
CBT and Medication
Evidence shows that CBT alone – without medication – successfully treats a host of mental health and psychiatric disorders. In fact, research shows CBT as effective as medication for mild-to-moderate depression, anxiety, trauma, post-traumatic stress disorder (PTSD), addiction, and borderline personality disorder (BPD). Since mental health professionals often avoid prescribing medication to children, many recommend CBT as the first line of treatment for children and adolescents struggling with mental health or behavioral issues such as oppositional-defiant disorder (ODD) or disruptive mood dysregulation disorder (DMDD).
Connecting Thought, Emotion, and Behavior
CBT offers practical solutions for dealing with problems by focusing on patterns of thought. CBT says that thoughts, emotions, and behaviors are all interrelated. What we think affects how we feel and act. Our behaviors affect how we feel and think. And our emotions affect how we act and think. Often, what we think is maladaptive – which can lead to psychological, emotional, and behavioral disorders.
In essence, CBT helps change negative thought patterns to positive ones. It helps transform behaviors that might be self-destructive into behaviors that are healthy and productive. Most importantly, CBT teaches individuals that they’re capable of handling anything that comes their way and gives them tools that empower them to lead the life of their choosing.