Cognitive Behavioral therapy (CBT) is a brief psychotherapy treatment which is directed at changing a person’s thoughts in order to improve their mood or functioning. It is used to treat a range of problems including anxiety, depression, and sleep difficulty. On average, it takes five months of weekly sessions lasting 50 minutes each to create a change.
Central Concepts of Cognitive Behavioral Therapy
Negative Thoughts and Emotions Impact Actions
CBT is based on the view that a person’s emotions and behaviors are directly affected by their thoughts about a situation, and therefore inaccurate or overly negative thoughts often result in feelings or behaviors that are not adaptive. For example, a discouraging thought such as “I can’t do this” will usually lead to a loss of effort and a poor outcome. Likewise, persistent anxious thoughts such as “What if….?” often lead to more anxiety-related physiological symptoms (increased heart-rate or sweating) and less likelihood of following through with a desired behavior.
Weekly homework assignments are a critical component of CBT. New approaches to problems are developed during each session; these may be new alternative thoughts or new behaviors. These new thoughts and/or behaviors must be practiced during the following week in order to lead to new and more adaptive emotions and behavioral responses.
A typical CBT session is structured with three main parts, each taking up to 20 minutes. The initial step is to assess the problematic behavior or mood, whether that is a persistent anxious mood or a behavior such as difficulty falling asleep. Concerns of the client are heard by the therapist and the effectiveness of the past week’s homework assignment is discussed. The second step in a session is to plan the next topic and relate that to the current concern of the client. The final third of the session involves planning a relevant and manageable practice exercise for the coming week and preparing for high-risk situations.
What Can CBT Help With?
CBT has been used effectively for both diagnosed disorders and other general issues. There are many types of disorders that have been treated with CBT, as well as specific diagnoses for which CBT has been shown most effective. There are also several general issues that have responded well to CBT treatment, which often occur without the full range of symptoms that might lead to a diagnosis.
Mental and Behavioral Disorders
The list of mental and behavioral disorders that have responded well to CBT treatment includes:
- Anxiety Disorders: Specific phobias, Post Traumatic Stress Disorder (PTSD), Obsessive-Compulsive Disorder (OCD), and Generalized Anxiety Disorder
- Somatic Symptom Disorders: formerly known as hypochondriasis and body dysmorphia
- Eating Disorders: Bulimia Nervosa, Binge-eating Disorder
- Mood Disorders: Bipolar Disorder, Major Depressive Disorder
- Substance Use Disorders: Tobacco Use Disorder, Cannabis Use Disorder
- Sleep Disorders: Insomnia
Other General Issues
- Anger control problems: Inappropriate expression of anger, driving rage
- General stress: Tension, excessive worry
- Sleep difficulty/random pattern of sleeplessness
Common CBT Techniques
There are six basic types of CBT techniques, all of which have been shown to be effective for various problems. While some are more thought-focused (cognitive restructuring, mindfulness), others are behavior-focused (SMART goals, graded exposure, skills training, scheduling activities). Homework assignments commonly involve practicing one or more of these techniques which are defined in more detail below.
Cognitive restructuring refers to the various strategies used to change thoughts which usually lead to anxious, sad, or otherwise distressed moods. Most often this is done by keeping a record of the distressing thoughts on a form, along with the incident that triggered the thought, the related emotion, and if relevant the resulting behavior. Alternative, more positive thoughts are then suggested, often with the help of the therapist.
Setting SMART Goals
This is a technique used early in CBT when behavioral change is the priority. Once the client has identified an overall goal such as “get more exercise,” the therapist and client will work together to clarify the new behaviors and the time frame. A SMART goal is Specific, Measurable, Achievable, Relevant, and Timely.
Graded exposure involves breaking down a feared situation into smaller steps that allow for a gradual approach to overcoming the fear. Behavioral homework is assigned in a way which allows the client to begin with the simplest step and work up to more difficult behaviors until the goal behavior is reached without excessive anxiety.
Skills training is used when specific types of skills are lacking, therefore making the desired outcome behavior very unlikely. This may involve learning social skills, assertiveness skills, or relaxation skills.
This is a very effective and practical behavioral technique. Specific behaviors which will be helpful in reaching a goal are added to the client’s daily or weekly schedule. These scheduled activities are usually short and simple such as taking a walk or spending a specific amount of time on a project that has been procrastinated.
Mindfulness is relatively new as a cognitive technique in CBT, although it has been used in meditation for centuries. Mindfulness is being aware of one’s current situation, emotions, or thoughts, and accepting them without judging them. By practicing this acceptance, one becomes less reactive to a stressor and more able to remain calm and respond effectively.
As noted earlier, CBT has been shown to be effective with a variety of problems, including diagnosed disorders and persistent but non-diagnosable issues. Following are some examples of situations in which CBT may be used effectively.
Generalized Anxiety Disorder
Jane is often worried about a number of different situations in her life. She has concerns about money and wonders how she will pay off her student debt. She worries about the security of her current job and suspects that she will be laid off if she arrives late to work again. She is also concerned about her own health, as she has frequent headaches which have been diagnosed as stress headaches by her physician.
In doing CBT with Jane, a few different techniques would be helpful. Cognitive restructuring would address the distressing thought of, “What if I am not able to make the payments on this debt?” Such thoughts could be replaced with more positive ones, such as, “I’m very fortunate to have the education that I received,” and practical thoughts such as, “I’ve made all the payments so far.” Concerns about being late to work could be addressed by setting a SMART goal for getting there with time to spare. Skills training such as deep breathing and other relaxation skills might be helpful for her stress headaches.
Anger Expression and Control of Anger
John reports that he too often feels irritable and flies off the handle almost every day over some small incident. He finds himself getting easily angered by other drivers, frequently honking the horn and cursing behind the wheel. A CBT approach for John might include scheduling activities such as regular exercise into his weekly routine in order to improve his general mood. Mindfulness practice would allow John to notice his anger in the moment, and skills training would help him learn to use deep breathing in order to calm himself in those angry moments.
Tobacco and Substance Use Problem
Joan has been using substances more and more frequently over the past year and has been advised by her physician to cut back on her use of tobacco products. She has been unable to control her own urges to use tobacco in spite of her decision to follow her doctor’s advice. Skills training may be used to help Joan change old habits associated with her substance use. The goal would be to substitute old habits with more positive, healthy activities and natural reinforcements. In addition, mindfulness techniques would likely increase her ability to manage the negative feelings that have sometimes led to the substance use.
How to Find a Cognitive Behavioral Therapist
Finding a therapist experienced in CBT is not unlike finding a qualified mental health provider in general. This is because many clinicians have experience with various cognitive and behavioral techniques. Standard advice is to check with health insurance provider lists, ask trusted friends or family if they can recommend someone, and then contact providers to ask questions which will help determine the best fit.
Specific certification is not required to conduct CBT, although it can be obtained. There are several major organizations in the US which offer certification as a Cognitive Behavioral Therapist. These include the National Association of Cognitive-Behavioral Therapists (NACBT), the Beck Institute for Cognitive Behavioral Therapy, and the Academy of Cognitive Therapy. These organizations require an undergraduate education in psychology, social work, or counseling, as well as graduate level (Master’s or beyond) training and clinical experience.
Cost of CBT and Insurance Coverage
The cost of CBT will depend on the number of sessions required to treat the severity and range of symptoms. However, the average number of sessions is around 20, given a presenting problem of generalized anxiety, for example. Cost per session varies greatly from a sliding fee scale (more often available in a community mental health clinic) to a private practice. The cost for CBT may range from as low as $20 per session to $180 per session, depending upon type of practice, geographic location, and provider’s experience level.
Most insurance plans cover CBT. There may be an annual deductible to be met first, and/or a copayment or a coinsurance amount per visit. Some health plans limit their coverage to a certain number of sessions per year. The client is advised to call their plan’s customer service representative and ask about benefits for outpatient mental health.
Key Questions to Ask a Therapist When Considering CBT
Assuming that practical concerns about cost, length of treatment, and scheduling options have already been discussed, there are key questions that will help a client decide whether the therapist is a good match for them in their current situation:
- How many years of clinical experience do you have?
- Did you attend an accredited training/educational program?
- How much experience do you have working with individuals whose symptoms were similar to mine?
- What is your estimate of the number of sessions I will need for relief of these symptoms?
- Would you recommend CBT for my presenting problems, or do you recommend another form of treatment?
What to Expect at Your First Appointment
The first appointment will include an assessment of the problems for which the client seeks help, establishing a positive working relationship, and explaining how CBT will be helpful. The basic concepts of CBT will be explained, including the critical role of homework assignments, and a general description of the variety of techniques that can be used.
The client will be asked to describe their current situation and related problems. Although CBT is present-focused, it may be necessary to provide some background information for the current problems. This is particularly true if there is a history of mental health treatment including outpatient psychotherapy, inpatient psychiatric care, or group/informational counseling. A therapist is able to design a more efficient treatment plan with the knowledge of the types of interventions which did or did not work well for that client in the past.
Along with making an assessment of the severity and range of problems, the first appointment establishes the beginning of a therapeutic working relationship. At this point a good relationship will have mutual trust in each other’s honesty, respect, and caring. There should be a general agreement on the goals of therapy, as well as a cooperative approach to the work ahead.
Is CBT Effective?
CBT is the most widely studied form of psychotherapy. This is largely because the outcomes are often behaviors which can be measured in comparison to pre-treatment behaviors for those individuals. The effectiveness of CBT has been reported by national organizations including the American Medical Association, the National Institutes of Health, and the Mayo Clinic. Hundreds of outcome studies have been conducted and have reviewed results of the use of CBT for a wide range of emotional and behavioral problems.
Here are some of the major conclusions of those studies:
The NIH published a review of 106 meta-analyses which had examined the efficacy of CBT over a broad range of problems.1 They found that the strongest support exists for the use of CBT in treating Anxiety disorders, Somatic Symptom disorders, Bulimia, anger control difficulty, general stress, and sleep difficulties.
Among the Anxiety disorders, very strong positive outcomes were found for the treatment of Obsessive-Compulsive Disorder. CBT involving the graded exposure technique was the most effective treatment for OCD. Similar positive results were seen in the treatment of Specific Phobias using graded exposure techniques. Moderately strong results were found in the use of CBT for Generalized anxiety, Social anxiety, and Panic disorder.
Among the Somatic Symptom disorders, very strong positive outcomes were found in the use of CBT for hypochondriasis and body dysmorphia. Likewise, very strong positive outcomes were found in the treatment of bulimia, anger control issues, general stress, and insomnia.
Strong outcomes were reported in the treatment of addictions, particularly cannabis and nicotine use disorders. Less positive results were found for the use of CBT in treating abuse of opioids and alcohol.
The NIH also published a review of outcomes for CBT in the treatment of Mood Disorders (Major Depression, Bipolar Disorder, chronic mild depression). They concluded mixed results in terms of efficacy of CBT for these disorders. There was support for CBT’s helpfulness in overcoming acute depressive episodes.2
A summary of outcomes reported by the Mayo Clinic indicated that CBT was very effective in treating Specific phobias, and also very effective for anger control problems, stress management, and insomnia.3
A recent study reported in the Journal of the AMA reviewed the results of 69 randomized clinical trials which included over 4,000 patients. They found a large reduction in anxiety symptoms for 12 months following CBT treatment of PTSD, and a moderate reduction of symptoms for 12 months following the treatment of generalized anxiety disorder and social anxiety disorder. Surprisingly, they did not find significant results for CBT treatment of OCD.3
Risks of CBT
The risk involved in CBT is limited to the possibility of experiencing strong emotional reactions, such as fear or anxiety, particularly when using graded exposure techniques. Feelings of anger, temporary stress, or emotional exhaustion may also occur, as they might in any form of psychotherapy.4
Criticisms of CBT
One common criticism of CBT is that its focus upon the thoughts and behavior in the present time may lead to underestimating the importance of past experiences and related emotions which have been repressed and yet are still an important part of the whole person. However, this criticism loses meaning as long as the treatment does lead to lasting changes and relief of symptoms.
Secondly, CBT has been criticized as lacking a basis in the current theory and knowledge about the human cognition. It was developed largely based upon clinical work and observation of results of cognitive and behavioral interventions. It isn’t directly connected to theories about how we learn, or about our ability to reason through use of logic.5
A third criticism occurs when CBT is broken down to its two major components, behavioral and cognitive. The two components have been offered separately in the treatment of patients with a diagnosis of depression. In one study, depressed patients improved as much after treatment with only behavioral techniques as compared to patients who received both behavioral and cognitive (CBT) techniques.6 This outcome raised questions about the value of adding the cognitive interventions.
How is CBT Different from Other Therapy Techniques?
CBT vs. DBT
Dialectic Behavior Therapy (DBT) is a specialized form of CBT in which four particular skill sets are taught and practiced. These are: Mindfulness skills, Interpersonal effectiveness skills (including assertiveness training and problem-solving), Distress tolerance skills (including self-soothing, thinking of pros and cons in a difficult situation), and Emotion regulation skills (such as identifying emotions and taking actions opposite to the habitual maladaptive response). DBT was initially designed to help individuals who often react with intense emotions, particularly when they interact with family members, close friends, or romantic partners.
Unlike CBT, many DBT treatment plans include a weekly group session in which these sets of skills are taught and practiced. Due to its focus on emotion management, DBT has been shown to be the more effective approach to treatment of individuals with Borderline Personality Disorder.5
CBT vs. ACT
Acceptance and Commitment Therapy (ACT) is another offshoot of CBT to the extent that it also involves a focus on being mindful of one’s thoughts. However, ACT involves the acceptance of thoughts as they are, along with a commitment to behavioral changes. The assumption is that thoughts do not need to be changed (restructured) in order for feelings and behaviors to change. The focus in ACT is to change patterns of avoidance behaviors in particular.
In some outcome studies, ACT has been shown to be an effective alternative to CBT in the treatment of Obsessive Compulsive Disorder.
CBT vs. EMDR
Eye Movement Desensitization and Reprocessing (EMDR) is a psychotherapy process in which a client is asked to recall a traumatic memory while the therapist directs them to follow specific eye movements, sounds, or taps. Its purpose is to allow the brain to recover in a natural way from traumatic events or memories. In theory, the brain’s response to the trauma is being rewired by these techniques until the original fight, flight, or freeze response fades out.
EMDR has been used as effectively as CBT in the treatment of PTSD.7,8 It differs from CBT in that there are no specific homework assignments and no focus upon changing thoughts or behaviors.
CBT vs. Insight-Oriented Therapy
Insight therapy is directed toward understanding the causes of the presenting emotions and behaviors. The assumption is that a client will be able to change their distressing thoughts or actions once they become aware of the unresolved problems and emotions from the past. This form of therapy is usually less directed by the therapist, less reliant upon homework, and requires more sessions.
There is some evidence that insight-oriented therapy may be more effective than CBT in the treatment of Personality disorders.8
History of Cognitive Behavioral Therapy
CBT has been described as having developed over a series of 3 major waves. The “first wave” of CBT was the development of behavior based therapy. Its roots date back to the 1920s, when the study of behavior led to knowledge about classical conditioning (Ivan Pavlov, John Watson). This was followed in the 1940s by experiments in operant conditioning (B.F. Skinner). Knowledge of these two forms of learning (classical and operant) contributed to the use of behavioral techniques for unlearning unwanted behaviors and learning new adaptive behaviors.
A “second wave” of CBT’s history occurred in the 1950’s and 1960’s. The earliest cognitive-based therapy is credited to Albert Ellis, who introduced Rational Emotive Behavior Therapy (REBT) in 1955. Ellis focused upon the basic beliefs that we tend to have about ourselves and others, and how to identify and challenge those beliefs which are irrational, particularly those which result in feelings of anger. At roughly the same time, Aaron T. Beck was using cognitive therapy in his clinical work to help clients recognize the negative thoughts that contributed to feeling depressed. He and his daughter, Judith Beck, continue to operate the Beck Institute for Cognitive Behavioral Therapy.
During the 1980’s and 1990’s the cognitive and behavioral elements of these earlier approaches merged into the current approach described here as CBT, as well as its offshoots, DBT and ACT. This period of merging followed by the development of specialized approaches has been called the “third wave” of CBT. Looking ahead to the future, the effectiveness of CBT will likely increase as more research is done to identify the predictors of positive outcomes, as well as the factors which moderate the desired outcomes.