Cognitive Behavioral Therapy: How It Works & What To Expect

What Is Cognitive Behavioral Therapy?

CBT is built on the belief 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 can benefit from changing their thought patterns and exploring the influence of their feelings.

How Does CBT Work?

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 the desired goals.²

Why Does CBT Work?

Here are a few of the key reasons why CBT can be very effective:

• Structure provided in sessions and the use of homework outside of sessions: CBT treatment works by giving the client immediately usable skills, and the client using the skills during their daily life in between sessions.
• CBT is primarily focused on the present: 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.
• The therapist and the client enter into a collaborative relationship to establish and achieve the wanted outcomes: 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.

Types of Cognitive Behavioral Therapy

CBT is a broad, general method of psychotherapy involving various principles and techniques from which several branches of psychotherapy have developed.

Here are some of the common offshoots of cognitive behavioral therapy:³

• Cognitive Therapy (CT): CT is grounded on the notion that identifying and changing distorted thoughts is central to improving the way someone feels. While CBT also focuses on such a premise, it goes one step further by seeking to modify negative behaviors which reinforce flawed thinking.
• Dialectical Behavioral Therapy (DBT): DBT centers around finding common ground between acceptance and tolerance of distressful emotions while also moving towards positive change. CBT, on the other hand, emphasizes altering negative thought patterns to encourage overall wellness.
• Multimodal Therapy: This holistic framework treats someone’s entire personhood by drawing from or combining multiple forms of therapies. Conversely, CBT generally focuses on a specific concern or problem as opposed to approaching the person as a whole.
• Rational Emotive Behavioral Therapy (REBT): REBT seeks to shift faulty core beliefs related to life circumstances with the goal of developing a healthier perspective about it. While CBT’s main objective is to change problematic behaviors by avoiding automatic negative thoughts.

What Can CBT Help With?

There are many types of disorders that can be 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.

Here are some common applications of CBT:

• CBT for anxiety disorders
• CBT for depression
• CBT for PTSD
• CBT for OCD
• CBT for social anxiety
• CBT for eating disorders
• CBT for insomnia

CBT can also help with issues like:

• Hypochondria
• Body dysmorphia
• Grief
• Relationship problems
• Anger control problems
• General stress
• Bipolar disorder
• Substance use disorders

Common CBT Techniques

There are several cognitive behavioral therapy techniques 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 involves 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.

Benefits of Cognitive Behavioral Therapy

There are many benefits to CBT, including its shorter timeline, versatility, its ability to boost someone’s self-esteem, and its long-term results. Because CBT offers an array of benefits it is often preferred over other therapy types, and many insurance companies cover CBT treatment plans.

Some of the benefits of CBT include:

• It is short-term and solution oriented
• Many people appreciate the structure
• Its versatility allows it to be adapted for use across various populations and settings
• It is a collaborative process between client and therapist
• It provides practical coping strategies that can be easily implemented
• It fosters healthier thinking, empowering people and enhancing their self-esteem
• Positive changes can often occur quickly
• It can lead to long-term results after treatment is complete
• In some cases, it can be as effective as taking medication

What to Expect in CBT Therapy

CBT can happen in-person or through online CBT platforms, with an individual or in a group session, for personal problems or as a couple. During sessions, you’ll work through addressing specific concerns with your therapist, who may ask you a series of questions to change your thinking about the problem. Then, you’ll likely be asked to complete homework assignments outside of sessions to help solidify the new pattern of thinking and behavior.

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. New exercises and techniques may be practiced.
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.

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.⁴ 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 be in 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 for most concerns.

Client/Therapist Confidentiality

Confidentiality is an important aspect across all types of therapies including CBT, as it can set the tone for a trusting and collaborative environment. Many people feel more at ease opening up in sessions knowing that what’s discussed remains private and can only be shared if they consent verbally or in writing.

Nonetheless, there may be occasions when therapists cannot maintain confidentiality. This may occur if there’s a serious threat to safety or if they’re required by federal or state law to report concerns.

The standard limits to confidentiality (which can vary from state to state) are generally applied when:⁵

• The person poses an eminent danger to cause harm or death to themselves or others in the very near future
• They are being abused physically, sexually, or emotionally or had been in the past and it wasn’t reported
• They are involved in child, elderly, or disabled person abuse
• They are unable to safely care for themselves

Is CBT Effective?

CBT is the most widely studied form of psychotherapy, and it has been found to be effective for a range of concerns. 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. 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.¹
• 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.⁶
• An analysis of 20 studies found that online CBT options were as effective as in-person CBT for depression and anxiety.⁷

CBT Has a Long History as an Effective Treatment

CBT has been described as having developed over a series of three 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.⁸

Criticisms of CBT

Here are three common criticisms of CBT:

• One common criticism of CBT is that its focus on 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.
• 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.⁹
• 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.¹⁰ 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 several factors that you may want to keep in mind when seeking and beginning treatment. You need to be ready to engage in the structure of sessions and grapple with some of your difficult feelings, though you won’t be asked too much about any past wounds or trauma. You also need to be willing to do the homework and be willing to change your behavior, otherwise CBT will not be successful.

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 See Improvements

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.

How to Get the Most Out of CBT

CBT has been shown to be the golden standard of treatment for its effectiveness, but you also have to be willing to work hard in order to see the best results. The more you engage in the process by being honest with your therapist (and yourself!), doing your homework, and sticking to your treatment plan, the more likely you are to see lasting change.

If you want to reap its benefits and get the most out of your CBT sessions, consider the following:

• View your therapist as your partner: A CBT counselor’s role is to work alongside you to go through this process together. Approach therapy as a team effort. If you don’t feel you have a good partnership with your therapist, you might want to try someone else.
• Be honest about what you’re experiencing: Therapists act as a neutral party who will listen without judgment. That’s why it’s important to be truly honest about what you’re experiencing so they can better help you.
• Stick to the treatment plan but be open about what might not be working: Remember that you’re involved in every step of your treatment plan. If something isn’t working, share your concerns with your counselor to find other techniques that may be more suitable.
• Do your homework between therapy sessions: Benefiting from CBT psychotherapy requires effort and dedication on your end.  As such, complete homework, practice your skills, and genuinely try implementing the recommendations you’re provided with.
• Don’t expect instant change: Although you may start to see some improvements when you enter therapy, keep in mind that meaningful and sustainable changes take time.

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:

CBT for 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.

CBT for Anger Management

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.

CBT for 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.⁹

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.^11,12

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.¹³

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. You can check with health insurance provider lists or 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?