What is cognitive behavioral therapy (CBT)?

A brief overview of CBT

Cognitive Behavioral Therapy is often a short-term therapy. People who start CBT might be trying to manage a struggle with a particular thing, for example, an obsessive thought or an substance use disorder.

In CBT, your therapist will work with you to understand patterns you have learnt and how to re-learn those mental routines to find different outcomes. Most CBT involves practicing outside of therapy sessions and doing work to observe your own patterns and try to change them.

CBT sessions are usually highly structured, working through different techniques with the person to understand their processing, and reflect on the work they have done outside of the session.

CBT is an incredibly widely used and prescribed type of therapy, for example, in England it is offered to anyone through the NHS because of its effectiveness. ^[1] It is applicable in lots of different settings and can benefit very different kinds of people, so in the clinical community it is understood as the 'gold standard' for psychotherapy, or talking therapies. ^[2]

What does CBT stand for?

CBT stands for Cognitive Behavioral Therapy, a type of talking therapy that explores the relationship between thoughts, feelings, and behaviors.

Cognitive

The cognitive element of this type of therapy relates to the parts in which you examine the things you think, the patterns those thoughts form, like rumination, and how to re-route these sequences.

Behavioral

The behavioral element of this type of therapy relates to the parts in which you examine the things you do, why you do them, for example, which thought patterns are connected to them and what prompts or triggers them. 

One of the key elements of CBT is unpicking the extent to which your thoughts and behaviors are connected. An example of a thought/feeling/behavior cycle could be the thought or belief that you’re not very clever is triggered by getting something wrong at work, this prompts a feeling of worthlessness which plays out in your behavior towards colleagues - withdrawing from them or getting very angry. 

CBT can help you to break what might feel like inescapable or endless cycles of thoughts, feelings and behaviors in your daily life. 

What is the goal of cognitive behavioral therapy (CBT)?

The main goal of cognitive behavioral therapy is to learn to use tools to empower yourself to take control over patterns of thinking, beliefs and behaviors that are limiting your quality of life. 

In order to do this, you work with a therapist to identify a clear and achievable goal you want to achieve through CBT. You will then work together to look at the feelings, thoughts and actions that are preventing you from reaching that goal, and how connected they are.

You will try different strategies, tools and techniques to spot when these feelings, thoughts and behavior sequences are cropping up in your life before exploring how you can change them.

Ultimately, the goal of CBT will always be to change your current reality and how to develop effective coping strategies to deal with whatever life throws at you.

What is CBT used to treat?

Cognitive behavioral therapy is one of the most commonly used and prescribed types of talking therapy around the world. As well as treatment for mental health conditions, CBT can be used to improve general well-being and relationships, and to tackle issues like substance use disorders.

People enter this type of therapy for support with a wide range of mental health concerns, from common ones like depression and anxiety disorders, to more severe ones like bipolar disorder. CBT for psychosis can also be used to treat individuals with schizophrenia, and is most effective when a person is psychiatrically stable enough to focus on guided problem-solving to reduce the severity of symptoms and likelihood of relapse. CBT has been shown to be particularly effective with people with generalized anxiety disorder, major depressive disorder, and bipolar disorder. ^{[3] [4]}

CBT was first developed in the 1960s to treat depression, to offer an alternative to medication, and is still commonly offered as a treatment for this mental health condition. Some studies show that as well as helping people to cope with their depression in the immediate, people who have gone through CBT are less likely to relapse to the level of depression they experienced before entering therapy. ^[5]

Research has also shown how effective CBT can be in a very short space of time, particularly in comparison to other types of talking therapy, so it is also a cost effective option for people and health systems. ^[6] For some people, as few as six sessions can be enough to reach their desired goal.

As well as those already mentioned, some other examples of mental health conditions CBT is used for include:

• Eating disorders
• Post-Traumatic Stress Disorder 
• Panic disorder and phobias ^[7]
• Obsessive Compulsive Disorder ^[8]

What are common CBT techniques?

Most types of therapy are based on a set of beliefs or theories about human behavior, which are then tested through different techniques. According to the American Psychological Association, the primary beliefs in cognitive behavioral therapy are that:

• Psychological issues are partly based on unhelpful ways of thinking
• Psychological issues are partly based on learned patterns of behavior
• People living with these issues can improve with better coping mechanisms and management to help relieve their symptoms ^[9]

Some of the techniques that your therapist might work with you on include: 

Thought recording 

This involves observing your own patterns of thinking, writing down thoughts when they come into your mind, when they happened and what seemed to prompt them or whether they were unsolicited. ^[10]

Journaling or keeping a mood diary

This means noting down your feelings at different points between sessions and reflecting on your mood around certain activities. This might include planning activities that make you feel uncomfortable, anxious or low and then noting down exactly how that emotion developed and subsided. This is sometimes called ‘situation exposure’. 

Using a ‘worry bucket’

This can be done as part of thought recording and means noting down a thought that is worrying you or making you feel anxious when it crops up, but deciding not to dwell on it until a particular point later in the day. It is likely that by the time you get to the point in the day when you confront these thoughts, they will seem far less worrying than they did at the time.

Role play

You might work with your therapist to re-enact situations that crop up in your life to examine the feelings and thoughts that come up for you and how this leads to certain behaviors. Your therapist might challenge you during the role play to think about how the situation could play out differently if your thoughts and behaviors were different. You might also use this technique to prepare for a stressful situation you know is coming up. ^[11]

Whichever techniques your therapist uses with you, the key underlying goal will be to spot where your patterns of thought and assumption are leading to issues and help you to weigh up whether they are based in reality. This might also include challenging your beliefs about others and why they behave the way they do.

Through applying the techniques you should begin to learn how to navigate situations differently on your own and so gain more confidence in your ability to tackle difficult circumstances.

Is there only one type of cognitive behavioral therapy

There are some adaptations of CBT, which can benefit people with particular diagnoses or who want to tackle a particular issue, for example, trauma-focussed CBT. Other types of cognitive therapy include:

Dialectical Behavior Therapy (DBT)

Dialectical Behavior Therapy (DBT) originated from the same school of thought as CBT and focuses on self-acceptance and learning to regulate your feelings.The use of ‘dialectical’ means this therapy aims to help someone to bring together two things that seem opposite - that they can accept who and how they are while also trying to achieve change.

In DBT you will work on developing skills to cope with distressing or difficult life situations and how to cope with emotions that unsettle you when they come up. DBT can include working in groups with others and is often used with people who have borderline personality disorder.

Exposure therapy

This is a type of behavioral therapy, which does not focus on the cognitive processing around behaviors. It can include exposure therapy, for example, working with someone with OCD to become less anxious about the subject of an obsession, and lessen the use of compulsive behaviors to cope.

What should you expect in a CBT session?

First session

No two sessions of CBT will be the same and how your session goes will depend in part on your therapist and on your own therapy goals. In most sessions, a therapist will start by asking about your feelings, how they are affecting you and your relationships. They might also ask about the physical impact of your feelings, for example, whether your stress is creating aches and pains. 

You will also sort out a working agreement with your therapist in the first session, covering confidentiality, discuss your goals and when to review them and you might also agree on a crisis plan if necessary, for example, who to call if you are having a psychotic episode.

Later sessions

Beyond your first session, a typical CBT session might involve talking about things that have happened since your last session, looking through any work you did in your own time, doing some exercises with your therapist and reviewing the progress you’ve made towards your goals.

Most CBT involves doing work outside of the session, so it’s important to set aside enough time to do this before each of your sessions. As well as individual sessions, CBT can also be done in a group or as a form of couples therapy, with a romantic partner.

Therapy settings

Therapy also now takes place in a variety of settings, and there is a greater diversity of therapists available. If you haven’t engaged in therapy before, you might picture a session looking like lying on a couch while another, older person interprets your thoughts and behaviors, but many people now engage in therapy through apps, video calls, over the phone or in their office.

Recent research shows that remote CBT can work effectively, which might make it a good option for talking therapy for even more people. More research is needed to understand how best to do CBT online and whether a mixture of face to face and virtual treatment could also be beneficial, but initial results suggest that digital CBT is effective. ^[12]

How do I know if CBT is right for me?

While CBT is a very popular type of talking therapy, it’s not for everyone. If you are looking for therapy that is very focused on the current problems you’re facing instead of focusing on past experiences, CBT could be right for you .

Many people enter CBT because they want to learn how to manage a specific issue or struggle, rather than to gain a better general understanding of themselves. CBT takes a highly practical approach but it can still take some time to see the effects, so give it at least a few sessions before you make a decision about whether or not it’s right for you.

As well as being used to treat a range of mental health problems, you might enter CBT because of a stressful life event like a relationship break up, the loss of a job, bereavement or trauma. There is also evidence to suggest that CBT can be effective among younger people. ^[13]

What to think about before starting CBT

Before entering therapy, it is important to consider your mental health and which type of therapy best fits what you are trying to achieve. If you have a specific diagnosis, you might want to try a type of therapy commonly used to treat it, for example, CBT is particularly effective for people with depression, anxiety and OCD.

The duration of Cognitive Behavioral Therapy tends to be shorter than in other types, usually lasting a few weeks and rarely longer than a few months. If you are considering the cost of your therapy, CBT is often the most affordable option.

Depending on whether you have a mental health problem and on its severity, you might need to take medication alongside doing this type of therapy. There is some evidence to suggest that for some diagnoses like mild depression, CBT on its own can be just as effective medication.

It is possible to see great results from Cognitive Behavioral Therapy, but if your therapist is not sure you can make the progress you want to with CBT or with them, they should recommend that you work with somebody else or try a different approach.