Cognitive Behavioral Therapy (CBT) is an evidence-based treatment that has been shown to be effective at treating depression, anxiety, substance use disorders, and eating disorders. It is based on the belief that these problems are caused by unhelpful ways of thinking and behaving, and that treatment should involve changing these unhelpful thinking and behavioral patterns. In essence, once an individual starts to think about themselves and the world differently, they will then start to feel and act differently as well. For example, a client utilizing CBT for social anxiety would need to challenge negative assumptions about what others are thinking of them while also challenging themselves to not avoid social situations. Over time, they will start to feel less anxious in social situations as a result.
History of CBT
Before CBT, psychoanalysis and psychodynamic therapies were the primary options for people seeking 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, psychoanalytic 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 before seeing any change. The primary role of the therapist was to listen, accept, and reflect.
In contrast, CBT focuses on change and concrete goal setting in the present. 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:
- Generalized anxiety
- Social anxiety
- Substance use disorders
- Eating disorders
- Oppositional defiant disorder
- Disruption mood dysregulation disorder
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 world. 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 assessment 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.
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 complete 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 going to 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 going 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 CBT Interventions
Behavioral Activation (BA) is a CBT skill that focuses specifically on how behaviors can change emotions. It encourages teens to participate in activities that produce positive emotions and to accomplish small, meaningful tasks on a regular basis. Research shows that engaging in pleasant and mastery-building activities increases positive emotions and reduces the sadness associated with depression.
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.
What’s the Difference Between CBT and DBT?
Many people have questions about the differences between CBT and DBT. We’ll clarify those differences now.
CBT is a change-oriented treatment—focus is largely placed on changing thoughts. This differs from DBT in that DBT incorporates acceptance strategies as an essential treatment component. Rather than jump to pushing for immediate change, the DBT therapist pauses in acceptance first by validating the valid of the client’s experience. As Marsha Linehan wrote in her book Cognitive Behavioral Treatment of Borderline Personality Disorder:
“DBT is very simple. The therapist creates a context of validating rather than blaming the patient, and within that context the therapist blocks or extinguishes bad behaviors, drags good behaviors out of the patient, and figures out a way to make the good behaviors so reinforcing that the patient continues the good ones and stops the bad ones.”
While many clients can benefit from the change-focused approach of CBT, particularly those primarily experiencing depression and anxiety, clients with high emotion sensitivity and difficulties with emotion dysregulation may find CBT less helpful. In these cases, the acceptance strategies and the biosocial lens of understanding their problems in DBT are key to helping these clients move towards change.
CBT and Medication
Evidence shows that CBT alone – without medication – can successfully treat a host of mental health and psychiatric disorders. In fact, research shows CBT is as effective as medication for mild-to-moderate depression, anxiety, trauma, post-traumatic stress disorder (PTSD), and substance use disorders. 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).