Cognitive behavioral therapy (CBT) is a tool used to treat a number of mental and physical health issues, and due to its flexibility, CBT online offers many of the benefits found in the face-to-face model. CBT is widely available online, so people experiencing unwanted symptoms linked to anxiety, depression, and other conditions should view it as a viable option to treat their overall well-being.
Central Concepts of Cognitive Behavioral Therapy
At its core, online CBT still holds true to the central concepts of in-person cognitive behavioral therapy.
The Interconnectedness of Thoughts, Feelings, and Behaviors
The cornerstone of any CBT treatment is the interconnectedness and bidirectional relationship of thoughts, feelings, and behaviors.
CBT is based on the notion that:
- Thoughts affect behaviors and feelings
- Behaviors affect thoughts and feelings
- Feelings affect thoughts and behaviors
A triangle with thoughts, feelings, and behavior at the points often is used as a way to visualize the connection between these elements of each person, and illustrate the relationship.
With these ideas in mind, CBT therapists believe that unhelpful ways of thinking and behaving lead to psychological problems.1 A person with unwanted feelings linked to depression or anxiety can focus on changing their thoughts and behaviors to shift the way they feel. Someone with unwanted behaviors like compulsions or addictions will benefit from changing their thought patterns and exploring the influence of their feelings.
Time-Limited, with Structured Sessions and Homework
Sometimes therapy sessions can go on for many months or even years, but the aim of CBT is to offer impactful, time-limited sessions. By offering sound therapeutic techniques, many people will have a complete course of CBT in 16 sessions or less, depending on the complexity of the distress and desired goals.2
One way CBT is able to offer strong results in a short amount of time is the structure provided in sessions and the use of homework outside of sessions. CBT treatment works by giving the client skills, and the client using the skills during their daily life in between sessions.
Each session will focus on:3
- Reviewing the previous session
- Discussing noteworthy events that transpired since the last session
- Reviewing homework
- Setting the agenda for this session
- Summarizing and concluding session
Sessions will always vary, but this general framework will anchor many CBT sessions.
Focused on Present Life and Events
CBT is primarily focused on the present—the here and now. It is more interested in how you feel, behave, and think right now than how you thought, felt, and acted years ago.2 Though noting the differences between the past and present can help gain useful information.
By focusing on the present, CBT hopes to make significant modifications to how a person feels in the future. Other treatments may focus on understanding why someone is feeling a certain way or why they respond in dysfunctional ways, but CBT desires change.
Though CBT is present-oriented, it does attend to the past when needed. Often, in order to change patterns of thinking and behaving, a person sometimes needs to recall the history of the issue to identify the issues perpetuating the problem.
Therapeutic Relationship
In CBT, the therapist and the client enter into a collaborative relationship to establish and achieve the wanted outcomes. The therapist will assume different roles as a listener, a teacher, an encourager, and others throughout the course of treatment.2
At the center of the relationship is trust. Trust helps the client feel confident that the therapist has their best interests in mind. At times, the therapist may need to challenge the client to engage in a homework assignment or exercise that feels uncomfortable, and the trust will help them follow through with the process.
What Can CBT Help With?
With CBT’s long history of being researched and tested, the treatment style has been proven effective for a long list of mental health and physical health disorders. Even better, CBT skills can help people lead happier, healthier lives, regardless of their health status.
Mental & Behavioral Disorders
Since being introduced as a therapeutic technique designed for people with depression, CBT has expanded to treat numerous mental health disorders like:4
- Anxiety disorders like generalized anxiety disorder, phobias, and social anxiety disorder
- Bipolar disorders
- Depressive disorders like major depressive disorder
- Eating disorders like anorexia, bulimia, and binge eating disorders
- Obsessive-compulsive disorder (OCD)
- Post-traumatic stress disorder (PTSD)
- Sleep disorders like insomnia
- Sexual disorders
- Substance use disorders involving illicit or legal drug use
CBT is very effective when used alone for these conditions, but with the addition of medications, it could be even more helpful.
Other General Feelings/Issues
Because the treatment is so effective, CBT can also treat a number of physical health ailments. People may utilize CBT skills to improve conditions like:5
- Fibromyalgia
- Chronic fatigue
- Irritable bowel syndrome
It should be noted that these conditions are known to have a mental health component. Although CBT can help with these problems, the treatment is not a cure, so a person may need to explore other options and lifestyle changes to improve their symptoms further.
CBT is flexible enough to address other issues like self-esteem, public speaking, focus, and other issues that may disrupt a person’s ability to perform and feel well.
Common CBT Techniques
CBT is an expansive treatment option with a multitude of techniques a professional can use and recommend to address symptoms. Some of the most common and most valuable CBT techniques include functional analysis and skills building.
Functional Analysis
Through functional analysis, the CBT professional will work with the client to build a complete understanding of the unwanted thoughts, feelings, and behaviors causing problems as well as the reinforcers and punishments in place. Then, the therapist can recommend thinking and behavioral changes that will shift the reinforcement schedules to produce more desirable consequences.2
Skills Building
In the therapist’s role as a teacher, they will offer many skills that hope to lower the symptoms and improve the happiness of the individual in treatment. Drawing from a vast set of skills, the CBT therapist will offer the options that best meet the client’s needs at the time.
Types of skills presented during CBT sessions include:
- Assertive communication skills to improve communication
- Stress management skills to identify and decrease the impact of stress
- Relaxation skills to calm the body and mind
- Anger management skills to avoid violent or harmful reactions to anger
Cognitive Reframing and Challenging Cognitive Distortions
Using the CBT framework, everyone has faulty and distorted ways of thinking and seeing the world. Called cognitive distortions, these thoughts can make depression, anxiety, and any other mental health condition worse.
Some cognitive distortion examples include:3
- Black or white thinking: Seeing situations as either all good or all bad with no gray areas
- Catastrophizing: Assuming the worst possible scenario will happen in any situation
- Mind reading/fortune telling: Thinking you know what someone is thinking in a situation
Cognitive reframing helps the clients to view themselves and the world around them in a more hopeful, truthful, and optimistic way. By challenging these distortions and using cognitive reframing, a person can limit their unwanted impact.4
Behavioral Changes
In some situations, the cognitive reframing and thought changes will produce the desired outcomes, and other times, the client must change their behaviors to improve their symptoms. CBT stresses the importance of the clients exposing themselves to people, places, and things that cause them distress. When using the CBT skills of facing their fears, usually slowly and over time, the client gains power and control over their triggers.1
Clear Goal Setting
Part of the collaborative efforts of CBT involves goal setting. The therapist and client will work to establish treatment goals that are SMART:
- Specific
- Measurable
- Attainable
- Realistic
- Timely
Clear goals help the therapist and the client stay focused and continue moving treatment on the desired path. Without clear goals, progress slows and more sessions are required.
Online CBT Examples
Whether online or in-person, CBT sessions generally will follow a similar path for similar problems.
CBT for the Fear of Heights
Specific phobias, like a fear of snakes or a fear of heights, are effectively treated with CBT through a process of systematic desensitization. Here, a client will discuss their fear with a therapist before building a list of situations that cause fear related to heights.1
After a period of skill-building to learn relaxation techniques, the therapist will encourage the client to start by engaging in a situation that triggers a low level of distress. Over time, the client moves through their list by challenging themselves to complete more distressing tasks until they reach the scariest item.
Since most of these behaviors take place outside of the session, the appointments focus on processing the previous events, encouragement, and planning for the next item.
CBT for Depression
After a thorough functional analysis of depression and its impact on the client’s life, the sessions shift towards the therapist providing education and skills linked to cognitive distortions and reframing.
The client and therapist can work together to identify the cognitive distortions with the most significant impact and begin challenging them. With homework assignments geared towards identification and reframing, sessions continue to refine the skills until the client has successfully changed their thinking habits.
CBT for Substance Use Disorders
Working with a present orientation, CBT for substance use disorders will begin with education pertaining to the impact of substances in the body and brain.
Therapeutic interventions will focus on:
- Identifying the people, places, and things that trigger thoughts of use
- Engaging in the cognitive reframing process to help build new and maintain established healthy habits
- Learning healthy coping skills to improve distress tolerance, relaxation, and communication
- Creating a relapse prevention plan that outlines the specific techniques to use when cravings occur
CBT sessions may also focus on understanding the history of use and the role of underlying co-occurring mental health conditions that promote addiction and dependence. By addressing the present functional analysis and the past reinforcers, the client and therapist can gain a complete picture of the presenting problem.
How to Find a CBT Therapist Online
With the advances and widespread acceptance, finding CBT online will be as simple as finding CBT in-person. In some ways, CBT online may be more accessible than traditional CBT sessions, especially for people with restrictive schedules.
When setting out to find CBT online, a person must consider what types of treatment they seek. Online CBT may involve phone calls, video chats, text-based therapy, specialized apps, and even standardized online programs that offer very little therapist contact.
Some names for online CBT include:
- Telehealth
- Teletherapy
- Telepsychology
- Online therapy
- iCBT
- Internet therapy
When deciding between treatments, ask yourself how much contact you desire with a therapist. Some therapies, like iCBT, provide lesson plans built on CBT fundamentals for an affordable cost, but they tend to lack personalized care from a therapist.
Who is Able to do CBT Online? Are Additional Certifications Needed?
For people interested in receiving CBT online, they will encounter many options for their treatment. Those seeking a personalized touch can encounter psychiatrists, psychologists, social workers, counselors, and other therapists available to offer sessions. Although these professionals will differ in their education and experience, they will all carry a license in their state to practice as a mental health professional.
It is unlikely they will possess an additional certification to practice online, but they may have participated in continuing education programs to become more effective in an online setting.
Cost of Online CBT
The average cost of online CBT may range from $20 to $250 per session, while some providers may offer monthly or yearly subscription fees in exchange for a set amount of access.
Because of the nature of online CBT, it will typically cost no more than an in-person session. People looking for the most cost-effective options can find apps that cost as low as five dollars.8 These programs cannot replicate the benefit of a therapist, but they could serve as a way to test CBT and online CBT as helpful treatment strategies.
Key Questions to Ask a Therapist When Considering Online CBT
With the service being relatively new, there will be vast differences between online CBT providers, so asking questions will be essential to find an appropriate match. Not every therapist uses CBT, so you will also need to specifically ask if it will be used.
Consider asking your potential online therapist:
- What are your credentials for providing online CBT?
- Will you charge my insurance or do I pay out-of-pocket?
- How will you maintain my privacy and confidentiality?
- How can I contact you between appointments?
- Do I have the option of seeing you in person if needed?
- Is CBT online an appropriate way to treat my symptoms?
- When would you expect my condition to improve?
No question is a bad question to ask at the beginning of therapy. CBT clinicians should provide clear and honest answers while considering a level of uncertainty with mental health concerns.
What to Expect at Your First Online CBT Appointment
Your first appointment of online CBT will contain many of the important facets of in-person CBT, just without the drive to an office, the time spent sitting in the waiting room, and the drive home. Online CBT can all happen from the privacy and comfort of your living room.
Like other forms of CBT, the first session of CBT online will cover elements like:4
- Learning about the therapist’s background, education, and experience
- Basic elements of CBT including its strengths and limitations
- Establishing firm goals for treatment
- Predicting how long therapy may be needed to achieve those goals
- Discussing how long each session lasts and the flow of sessions
- Disclosing the chief complaint and presenting problems that brought you to therapy
Because the therapeutic relationship is valuable in CBT but more complicated to form with online methods, the therapist may spend extra time and energy getting to know you. By asking questions about your favorite movies and music, the therapist can learn more about you while building a relationship built on trust and understanding.
The CBT therapist will discuss the level of access to treatment and options for forms of communication including phone, video chat, email, texting, and app access. Establishing a safety plan is also a key aspect of the initial therapy session.
Like its in-person counterpart, online CBT is an effective tool to treat a variety of physical and mental health conditions.
According to the American Psychological Association, online therapy treatments have been effective in treating:6
- Depression
- Anxiety and high stress
- Panic disorder
- Schizophrenia
- High blood sugar
- Overweight people
- Addictions and substance use disorders
One study found that online CBT sessions for people with depression yielded results that equaled a group receiving face-to-face treatments. Three months after treatment, though, the online therapy group maintained their results while the in-person group experienced an increase in depressive symptoms.7 In this way, online CBT can offer an even greater benefit than traditional sessions.
Risks of Online CBT
All therapies carry some risks, and online CBT may have issues linked to confidentiality, rapport, and worsening symptoms:6
- Confidentiality: Knowing that the information a client shares with their therapist stays safe is paramount. A therapist could be conducting therapy in an unsecured location, they could be careless with client data, or they could utilize online services which are prone to breaches. In all cases, the client should seek providers who engage in measures to maintain privacy.
- Rapport: In CBT, the therapeutic relationship is a valuable component. The risk of online treatment is that building a strong relationship with someone electronically will be too challenging. Plenty of these obstacles exist in real life, so a person should be open and direct with their therapist to discuss issues.
- Worsening symptoms: CBT can be an uncomfortable treatment style, at times, because the therapist may encourage someone to confront the situations that trigger stress. Entering into this process unprepared could lead to worsening symptoms. This risk is present with in-person and online CBT sessions, but assessing symptoms online may be more complex for the therapist.
Criticisms of Online CBT
Criticisms of online CBT are no different than the critiques of other forms of CBT. Additionally, some people may protest the idea of automated programs like iCBT because these treatments may effectively remove the individualized attention and skill of a trained therapist. These programs may lack the personal touch of interventions tailored to the individual.
How Is Online CBT Different from In-Person CBT?
Online CBT will be able to replicate some of the best features of in-person CBT closely. The core principles, techniques, focus on homework, and effectiveness of CBT will remain in place when the treatment moves online.
CBT, when performed online, will provide a few positive additions such as:6
- Convenience: Early in the morning, late at night, or anytime during the day, online CBT is available to help address a person’s needs. Online options add a level of convenience that in-person therapy cannot match.
- Possibility for lower cost: Websites, apps, and other online providers can offer special pricing for people who do not wish to use their insurance. Over the course of treatment, these therapies could provide a lower cost compared to in-person treatments.
- A more comfortable experience: Many people feel much more comfortable communicating through their phones than another person face-to-face. With this ease of communication, fewer barriers to enter treatment exist, especially for people in their teens and early twenties.
- Increased accessibility: Someone in a rural community could be very far from a mental health provider, and even if one is close, they may not offer the CBT treatment desired. Others will struggle to leave the home due to disabling mental or physical problems. Online options allow clients to choose between a number of providers, which inspires a sense of control over the process. It also can shorten the amount of time spent waiting for a therapist.
Though in-person treatments will always vary from online options, the gap is becoming smaller. As internet speeds improve and new technologies emerge, more parody between face-to-face and online therapy will exist.
Additional Resources for CBT
The most reputable names in mental health are studying the role of online CBT for people in need. Their work will help ensure the future of online CBT is safe, secure, and effective.
