Cognitive Behavioral Therapy: How It Works & What To Expect

What to Expect in CBT Therapy

CBT can happen in-person or online, with an individual or in a group session, for personal problems or as a couple. Here’s what you can expect from your CBT treatment plan:

At Your First Appointment

At the first appointment, you’ll be asked to describe your current situation and related problems. Although CBT is present-focused, it may be necessary to provide some background information for your current problems. There will also be a focus on developing a good relationship with your therapist, where you can have mutual trust in each other’s honesty, respect, and caring. There should be a general agreement between you on the goals you’re working toward. Finally, basic concepts of CBT will be explained, including the critical role of homework assignments, and a general description of the techniques that you’ll use.

At Ongoing Appointments

Whether individual or group, in-person or online, a typical CBT session is structured with three main parts, each taking up to 20 minutes:

1. The initial step is to assess the problematic behavior or mood, such as 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.
2. The second step in a session is to plan the next topic and relate that to the current concern of the client.
3. The final third of the session involves planning a relevant and manageable practice exercise for the coming week and preparing for high-risk situations.

There are several components of CBT that you can expect to work on with your therapist:

• Cognitive Restructuring: Cognitive restructuring refers to the various strategies used to change thoughts which usually lead to anxious, sad, or otherwise distressed moods.
• Setting SMART Goals: SMART stands for Specific, Measurable, Achievable, Relevant, and Timely.
• Graded Exposure: This involves breaking down a feared situation into smaller steps that allow for a gradual approach to overcoming the fear.
• Skills Training: This may involve learning social skills, assertiveness skills, or relaxation skills that may be lacking.
• Scheduling Activities: Activity scheduling involves planning out when you’re going to do specific life-giving activities. They’re usually short and simple such as taking a walk or spending a specific amount of time on a project that has been procrastinated.
• Mindfulness: 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.

How Long Does It Last?

The duration of therapy frequently depends on the condition, the recency of onset, and the presence of co-occurring mental and physical health issues. In mild cases of depression or anxiety that are recent and straightforward, therapy can help in just five or fewer sessions.¹³ When someone’s condition is more complex or recurrent, the therapy may need to be ongoing to effectively manage symptoms and maintain well-being. A person with PTSD, addiction, and diabetes may need to continue therapy for years.

How Much Does It Cost?

CBT Therapists typically charge $85-$130 per session. The cost of therapy can vary based on your location and the education of your therapist. Insurance often covers CBT, so many people will only have to pay a copay, bringing the cost down to $0-30 per session. If you don’t have behavioral insurance, you may be able to find a provider who offers a sliding fee scale based on your income.

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.

What Can CBT Help With?

There are many types of disorders that can been treated with CBT, and there are several specific diagnoses for which CBT has been shown to be most effective. There are also several general issues that have responded well to CBT treatment, which often occur without enough distressing symptoms to lead to a diagnosis.

The list of mental health concerns that have responded well to CBT treatment includes:

• Anxiety disorders
• Post traumatic stress disorder (PTSD)
• Obsessive-compulsive disorder (OCD)
• Social anxiety
• Hypochondria
• Body dysmorphia
• Eating disorders
• Major depressive disorder
• Bipolar disorder
• Substance use disorders
• Insomnia
• Anger control problems
• General stress
• Grief
• Relationship problems

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, eating disorders, anger control difficulty, general stress, and sleep difficulties.
• 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 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.³
• An analysis of 20 studies found that online CBT options were as effective as in-person CBT for depression and anxiety.¹²

CBT Has a Long History as an Effective Treatment

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 by Ivan Pavlov and John Watson led to knowledge about classical conditioning. This was followed in the 1940s with B.F. Skinner’s experiments in operant conditioning.

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. 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. During the 1980s and 1990s 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.

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

Here are three common 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.
• Secondly, CBT has been criticized as lacking a basis in the current theory and knowledge about 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.

What to Consider Before Starting CBT Treatment

While CBT can be incredibly effective for a variety of concerns, there are a variety of factors that you may want to keep in mind when seeking and beginning treatment.

Here are some things to consider before beginning CBT:

Change Can Be Very Hard

People are creatures of habit so ending the old and starting new, healthy behaviors is challenging. The same is true with thinking patterns. Anyone considering therapy should think about the effort needed to create the desired change, and if they are willing to put forth that effort. Without the effort, there can be no improvement.

CBT Is Really Structured

A person interested in a free and loose conversation about their past, present, or future should consider another form of therapy. CBT therapists may employ techniques that are very structured and specific for the individual’s needs. Of course, variation exists, but clients may have limited control about the structure and pacing of sessions.

It Can Be a Slow Process to Change

Because the process of changing the way a person thinks and acts is so challenging, the process can be slow, especially when symptoms are complicated. Being patient is essential, because if the person quits therapy prematurely, there could be many unresolved issues.

You Have to Be Willing to Change

Change is scary, and people often choose the comfort of the known instead of the discomfort of the unknown. Willingly choosing to embrace change takes tremendous courage, but it is the only way people can improve their situation.

CBT Examples

CBT has been shown to be effective with a variety of problems, including diagnosed disorders and persistent but non-diagnosable issues.

Here are some examples of CBT for specific situations:

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.

Control & Healthy Expression of Anger

John reports that he 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 & 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 Is CBT Different from Other Types of Therapy?

While CBT can be a very helpful approach for many, it’s not for everyone. Depending on your specific concerns, you may benefit from another type of therapy, or a therapist who uses a more eclectic approach.

Here are some key differences between CBT and other common forms of therapy:

CBT vs. DBT

Dialectic Behavior Therapy (DBT) is a specialized form of CBT in which particular skill sets are taught and practiced, such as mindfulness skills and assertiveness training. 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. 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. 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. 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

CBT vs. REBT

Rational Emotive Behavior Therapy (REBT) is a form of therapy created around the same time as CBT that focuses on many of the same principles and techniques as CBT. In fact, REBT is now viewed under the umbrella of CBT. REBT involves reviewing the client’s beliefs and identifying them as rational or irrational. The irrational are the source of emotional distress and must be adjusted to promote happiness.¹⁴

How to Find a Cognitive Behavioral Therapist

Finding a therapist experienced in CBT shouldn’t be difficult—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. Another simple way to find a therapist is by using an online therapy platform, where you can connect with therapists that practice CBT and have experience with your specific mental health concerns.

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?