In-Depth: Cognitive Behavioral Therapy

What Does CBT Treatment Look Like?

Cognitive-behavioral therapy differs from many other types of psychotherapies because sessions have a structure, rather than the person talking freely about whatever comes to mind. At the beginning of the therapy, the client meets the therapist to describe specific problems and to set goals they want to work towards. The problems may be troublesome symptoms, such as sleeping badly, not being able to socialize with friends, or difficulty concentrating on reading or work. Or they could be life problems, such as being unhappy at work, having trouble dealing with an adolescent child, or being in an unhappy marriage.

These problems and goals then become the basis for planning the content of sessions and discussing how to deal with them. Typically, at the beginning of a session, the client and therapist will jointly decide on the main topics they want to work on this week. They will also allow time for discussing the conclusions from the previous session. And they will look at the progress made with the homework the client set for him- or herself last time. At the end of the session, they will plan another assignment to do outside the sessions.

Doing Homework

Working on homework assignments between sessions, in this way, is a vital part of the process. What this may involve will vary. For example, at the start of the therapy, the therapist might ask the client to keep a diary of any incidents that provoke feelings of anxiety or depression, so that they can examine thoughts surrounding the incident. Later on in the therapy, another assignment might consist of exercises to cope with problem situations of a particular kind.

The importance of structure

The reason for having this structure is that it helps to use the therapeutic time most efficiently. It also makes sure that important information isn’t missed out (the results of the homework, for instance) and that both therapist and client think about new assignments that naturally follow on from the session.

The therapist takes an active part in structuring the sessions to begin with. As progress is made, and clients grasp the principles they find helpful, they take more and more responsibility for the content of sessions. So by the end, the client feels empowered to continue working independently.

Group sessions

Cognitive-behavioral therapy is usually a one-to-one therapy. But it’s also well suited to working in groups, or families, particularly at the beginning of therapy. Many people find great benefit from sharing their difficulties with others who may have similar problems, even though this may seem daunting at first. The group can also be a source of especially valuable support and advice, because it comes from people with personal experience of a problem. Also, by seeing several people at once, service-providers can offer help to more people at the same time, so people get help sooner.

How else does it differ from other therapies?

Cognitive behavioral therapy also differs from other therapies in the nature of the relationship that the therapist will try to establish. Some therapies encourage the client to be dependent on the therapist, as part of the treatment process. The client can then easily come to see the therapist as all-knowing and all-powerful. The relationship is different with CBT.

CBT favors a more equal relationship that is, perhaps, more business-like, being problem-focused and practical. The therapist will frequently ask the client for feedback and for their views about what is going on in therapy. Beck coined the term ‘collaborative empiricism’, which emphasizes the importance of client and therapist working together to test out how the ideas behind CBT might apply to the client’s individual situation and problems.

Who Benefits from Trying CBT?

People who describe having particular problems are often the most suitable for CBT, because it works through having a specific focus and goals. It may be less suitable for someone who feels vaguely unhappy or unfulfilled, but who doesn’t have troubling symptoms or a particular aspect of their life they want to work on.

It’s likely to be more helpful for anyone who can relate to CBT’s ideas, its problem-solving approach and the need for practical self-assignments. People tend to prefer CBT if they want a more practical treatment, where gaining insight isn’t the main aim.

CBT can be an effective therapy for the following problems:

  • anger management
  • anxiety and panic attacks
  • child and adolescent problems
  • chronic fatigue syndrome
  • chronic pain
  • depression
  • drug or alcohol problems
  • eating problems
  • general health problems
  • habits, such as facial tics
  • mood swings
  • obsessive-compulsive disorder
  • phobias
  • post-traumatic stress disorder
  • sexual and relationship problems
  • sleep problems

There is a new and rapidly growing interest in using CBT (together with medication) with people who suffer from hallucinations and delusions, and those with long-term problems in relating to others.

It’s less easy to solve problems that are more severely disabling and more long-standing through short-term therapy. But people can often learn principles that improve their quality of life and increase their chances of making further progress. There is also a wide variety of self-help literature. It provides information about treatments for particular problems and ideas about what people can do on their own or with friends and family (see further down).

Why do I Need to Do Homework?

People who are willing to do assignments at home seem to get the most benefit from CBT. For example, many people with depression say they don’t want to take on social or work activities until they are feeling better. CBT may introduce them to an alternative viewpoint – that trying some activity of this kind, however small-scale to begin with, will help them feel better.

If that individual is open to testing this out, they could agree to do a homework assignment (say to meet a friend at the pub for a drink). They may make faster progress, as a result, than someone who feels unable to take this risk and who prefers to talk about their problems.

How Effective is Cognitive Behavioral Therapy

CBT can substantially reduce the symptoms of many emotional disorders – clinical trials have shown this. In the short term, it’s just as good as drug therapies at treating depression and anxiety disorders. And the benefits may last longer. All too often, when drug treatments finish, people relapse, and so practitioners may advise patients to continue using medication for longer.

When individuals are followed up for up to two years after therapy has ended, many studies have shown a marked advantage for CBT. For example, having just 12 sessions of CBT can be as helpful in tackling depression as taking medication throughout the two-year follow-up period. This research suggests that CBT helps bring about a real change that goes beyond just feeling better while the patient stays in therapy. This has fuelled interest in CBT.

Comparisons with other types of short-term psychological therapy aren’t quite so clear-cut. Therapies such as inter-personal therapy and social skills training are also effective. The drive is now to make all these interventions as effective as possible, and also, perhaps, to establish who responds best to which type of therapy.

Cognitive behavioral therapy is not a miracle cure. The therapist needs to have considerable expertise – and the client must be prepared to be persistent, open and brave. Not everybody will benefit, at least not to full recovery, in a short space of time. It’s unrealistic to expect too much.

At the moment, experts know quite a lot about people who have relatively clear-cut problems. They know much less about how the average person may do – somebody, perhaps, who has a number of problems that are less clearly defined. Sometimes, therapy may have to go on longer to do justice to the number of problems and to the length of time they’ve been around. One fact is also clear, though. CBT is rapidly developing. All the time, new ideas are being researched to deal with the more difficult aspects of people’s problems.