In-Depth: Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is a short-term, goal-oriented psychotherapy treatment that takes a hands-on, practical approach to problem-solving. Its goal is to change patterns of thinking or behavior that are behind people’s difficulties, and so change the way they feel. It is used to help treat a wide range of issues in a person’s life, from sleeping difficulties or relationship problems, to drug and alcohol abuse or anxiety and depression. CBT works by changing people’s attitudes and their behavior by focusing on the thoughts, images, beliefs and attitudes that are held (a person’s cognitive processes) and how these processes relate to the way a person behaves, as a way of dealing with emotional problems.
An important advantage of cognitive behavioral therapy is that it tends to be short, taking five to ten months for most emotional problems. Clients attend one session per week, each session lasting approximately 50 minutes. During this time, the client and therapist are work together to understand what the problems are and develop new strategies for tackling them. CBT introduces patients to a set of principles that they can apply whenever they need to, and that’ll last them a lifetime.
Cognitive behavioral therapy can be thought of as a combination of psychotherapy and behavioral therapy. Psychotherapy emphasizes the importance of the personal meaning we place on things and how thinking patterns begin in childhood. Behavioral therapy pays close attention to the relationship between our problems, our behavior and our thoughts. Most psychotherapists who practice CBT personalize and customize the therapy to the specific needs and personality of each patient.
The History of Cognitive Behavioral Therapy
Cognitive behavioral therapy was invented by a psychiatrist, Aaron Beck, in the 1960s. He was doing psychoanalysis at the time and observed that during his analytical sessions, his patients tended to have an internal dialogue going on in their minds — almost as if they were talking to themselves. But they would only report a fraction of this kind of thinking to him.
For example, in a therapy session the client might be thinking to herself: “He (the therapist) hasn’t said much today. I wonder if he’s annoyed with me?” These thoughts might make the client feel slightly anxious or perhaps annoyed. He or she could then respond to this thought with a further thought: “He’s probably tired, or perhaps I haven’t been talking about the most important things.” The second thought might change how the client was feeling.
Beck realized that the link between thoughts and feelings was very important. He invented the term automatic thoughts to describe emotion-filled thoughts that might pop up in the mind. Beck found that people weren’t always fully aware of such thoughts, but could learn to identify and report them. If a person was feeling upset in some way, the thoughts were usually negative and neither realistic nor helpful. Beck found that identifying these thoughts was the key to the client understanding and overcoming his or her difficulties.
Beck called it cognitive therapy because of the importance it places on thinking. It’s now known as cognitive-behavioral therapy (CBT) because the therapy employs behavioral techniques as well. The balance between the cognitive and the behavioral elements varies among the different therapies of this type, but all come under the umbrella term cognitive behavior therapy. CBT has since undergone successful scientific trials in many places by different teams, and has been applied to a wide variety of problems.
The Importance of Negative Thoughts
CBT is based on a model or theory that it’s not events themselves that upset us, but the meanings we give them. If our thoughts are too negative, it can block us seeing things or doing things that don’t fit – that disconfirm – what we believe is true. In other words, we continue to hold on to the same old thoughts and fail to learn anything new.
For example, a depressed woman may think, “I can’t face going into work today: I can’t do it. Nothing will go right. I’ll feel awful.” As a result of having these thoughts – and of believing them – she may well ring in sick. By behaving like this, she won’t have the chance to find out that her prediction was wrong. She might have found some things she could do, and at least some things that were okay. But, instead, she stays at home, brooding about her failure to go in and ends up thinking: “I’ve let everyone down. They will be angry with me. Why can’t I do what everyone else does? I’m so weak and useless.” That woman probably ends up feeling worse, and has even more difficulty going in to work the next day. Thinking, behaving and feeling like this may start a downward spiral. This vicious circle can apply to many different kinds of problems.
Where Do These Negative Thoughts Come From?
Beck suggested that these thinking patterns are set up in childhood, and become automatic and relatively fixed. So, a child who didn’t get much open affection from their parents but was praised for school work, might come to think, “I have to do well all the time. If I don’t, people will reject me.” Such a rule for living (known as a dysfunctional assumption) may do well for the person a lot of the time and help them to work hard.
But if something happens that’s beyond their control and they experience failure, then the dysfunctional thought pattern may be triggered. The person may then begin to have automatic thoughts like, “I’ve completely failed. No one will like me. I can’t face them.”
Cognitive-behavioral therapy acts to help the person understand that this is what’s going on. It helps him or her to step outside their automatic thoughts and test them out. CBT would encourage the depressed woman mentioned earlier to examine real-life experiences to see what happens to her, or to others, in similar situations. Then, in the light of a more realistic perspective, she may be able to take the chance of testing out what other people think, by revealing something of her difficulties to friends.
Clearly, negative things can and do happen. But when we are in a disturbed state of mind, we may be basing our predictions and interpretations on a biased view of the situation, making the difficulty that we face seem much worse. CBT helps people to correct these misinterpretations.
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.
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.
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
- drug or alcohol problems
- eating problems
- general health problems
- habits, such as facial tics
- mood swings
- obsessive-compulsive disorder
- 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.
How Does Cognitive Behavioral Therapy Work?
How cognitive behavioral therapy works is complex. There are several possible theories about how it works, and clients often have their own views. Perhaps there is no one explanation. But CBT probably works in a number of ways at the same time. Some it shares with other therapies, some are specific to CBT. The following illustrate the ways in which CBT can work.
Learning coping skills
CBT tries to teach people skills for dealing with their problems. Someone with anxiety may learn that avoiding situations helps to fan their fears. Confronting fears in a gradual and manageable way helps give the person faith in their own ability to cope. Someone who is depressed may learn to record their thoughts and look at them more realistically. This helps them to break the downward spiral of their mood. Someone with long-standing problems in relating to other people may learn to check out their assumptions about other people’s motivation, rather than always assuming the worst.
Changing behaviors and beliefs
A new strategy for coping can lead to more lasting changes to basic attitudes and ways of behaving. The anxious client may learn to avoid avoiding things! He or she may also find that anxiety is not as dangerous as they assumed. Someone who’s depressed may come to see themselves as an ordinary member of the human race, rather than inferior and fatally flawed. Even more basically, they may come to have a different attitude to their thoughts – that thoughts are just thoughts, and nothing more.
A new form of relationship
One-to-one CBT brings the client into a kind of relationship they may not have had before. The ‘collaborative’ style means that they are actively involved in changing. The therapist seeks their views and reactions, which then shape the way the therapy progresses. The person may be able to reveal very personal matters, and to feel relieved, because no-one judges them. He or she arrives at decisions in an adult way, as issues are opened up and explained. Each individual is free to make his or her own way, without being directed. Some people will value this experience as the most important aspect of therapy.
Solving life problems
The methods of CBT may be useful because the client solves problems that may have been long-standing and stuck. Someone anxious may have been in a repetitive and boring job, lacking the confidence to change. A depressed person may have felt too inadequate to meet new people and improve their social life. Someone stuck in an unsatisfactory relationship may find new ways of resolving disputes. CBT may teach someone a new approach to dealing with problems that have their basis in an emotional disturbance.
How Can I Find a Cognitive-Behavioral Therapist?
You can find a cognitive-behavioral therapy by visiting the National Association of Cognitive Behavioral Therapists, who have a directory of certified cognitive behavioral therapists.
Because CBT is a generally taught and widely practiced psychotherapy technique, however, you can also find a therapist more generally via Psych Central’s Therapist Finder.
Can I Learn Some Cognitive Behavioral Techniques Myself?
Since cognitive-behavioral therapy has a highly educational component, much use is made of reading material in individual therapy and this has been expanded into a large self-help literature over recent years. Researchers haven’t paid much attention, so far, to whether these books can be helpful. There is one study of The Feeling Good Handbook, which they found effective for alleviating depression. This suggests that it could be beneficial for other problems, in the same way, although this will depend on the severity of the problem and how long it’s been going on.
Dave’s Story with Cognitive Behavioral Therapy
Dave is a 38-year-old gay man who had suffered disabling bouts of depression, on several occasions in his life, which caused him to make several career changes. He twice tried to commit suicide. He also suffered from a great deal of anxiety and stress, had some drink problems and found it difficult to control his temper, especially when drinking.
Dave was referred for CBT after a typical episode was triggered by stress at work. At his first meeting with his therapist, Dave already knew what he wanted to work on. He had a great sense of failure over his history of depression and what he called his lack of success in his career (‘I’ve really messed up’). He was anxious about his job prospects. He felt unattractive and was worried about ageing and about further losing his physical appeal. He felt his angry impulses were in danger of getting out of control.
In therapy, Dave learned to monitor his actions and his emotional responses. He began to plan activities that gave him a boost and to deal with situations that he had avoided through fear. He learned to identify when he was being extreme or biased in his thinking. He became good at examining his emotion-driven thoughts and reasoning them out so that he got things into proper perspective. His mood noticeably improved, and he began to tackle longer standing problems. He began looking at job prospects, by planning a more realistic choice of career, and sending in applications. He established a more equal relationship with his partner. He dealt with social situations, without demanding attention and special treatment from friends. Dave had to face up to problems that were difficult to take on board, such as his perfectionism and the unreasonable demands he made on other people. But Dave was highly motivated by the crisis in his life to find alternatives.
This is what he wrote towards the end of his therapy:
I have had many painful episodes of depression in my life, and this has had a negative effect on my career and has put considerable strain on my friends and family. The treatments I have received, such as taking antidepressants and psychodynamic counseling, have helped to cope with the symptoms and to get some insights into the roots of my problems.
CBT has been by far the most useful approach I have found in tackling these mood problems. It has raised my awareness of how my thoughts impact on my moods. How the way I think about myself, about others and about the world can lead me into depression. It is a practical approach, which does not dwell so much on childhood experiences, whilst acknowledging that it was then that these patterns were learned. It looks at what is happening now, and gives tools to manage these moods on a daily basis.
The work has moved on to look at deeper beliefs, which can dominate one’s life and cause loads of problems. For example, I have found that I have a strong entitlement belief [a belief that he is entitled to expect certain things from other people]. This is characterized by low frustration tolerance, anger, and inability to control impulses or be told what to do. It has been a revelation to look back on one’s life and see how this pattern has dominated a lot of what I have done. CBT has given me a feeling of being more in control of my life. I am now coming off medication and, with the support of my therapist and partner; I am learning new ways of being in the world. The challenge remains to change these thoughts and behaviors. It will not happen overnight.
Dave is a man who has applied himself very actively to change. As this quotation reveals, CBT offered him much more then the ‘quick’ fix that it is sometimes portrayed as giving.
Martin, B. (2016). In-Depth: Cognitive Behavioral Therapy. Psych Central. Retrieved on January 21, 2017, from https://psychcentral.com/lib/in-depth-cognitive-behavioral-therapy/