What is Cognitive Behavioral Therapy (CBT)?
If you’re curious about therapy, chances are that you’ve heard about, or at least seen the term, CBT out there. CBT stands for Cognitive Behavioral Therapy and it’s the leading form of evidence based treatment for mental, behavioral, and emotional health concerns. It’s the primary method of treatment that clients at my practice engage in to help them feel better and reach their goals. I’ve been studying CBT for over 10 years and training in it for the entirety of my career in mental health. Recently I was asked by My Wellbeing to provide a better understanding of what CBT is all about, what it looks like in the room, and more. I was so excited to offer a bit of what I know for their “Things we didn’t know…” series. Read through our conversation below or see the original post here.
1.How would you describe Cognitive Behavioral Therapy (CBT)?
CBT is a modern, evidence-based, empirically supported model of psychotherapy based on both scientific research and time-honored philosophy. In CBT, the client and therapist work actively in collaboration to help the client overcome problems rooted in the past, present, or future. The therapist aims to assist the client in changing unhelpful thinking, feeling, and behavioral patterns that contribute to their problems and develop skills to help manage life’s ups and downs. CBT is a problem-focused, action-oriented style of talk-therapy that teaches clients practical ways to identify, challenge, and replace unhelpful response patterns with adaptive, healthy thoughts, feelings, and behavioral patterns to reach one’s desired goals. CBT teaches clients to utilize these skills on their own with less and less reliance on the therapist over time.
2. How did CBT come to be? What types of philosophies inform it?
CBT came from an understanding supported by clinical research that feelings and reactions are created mainly by the beliefs we hold about and meanings we attach to our experiences. CBT recognizes that psychological disturbance is primarily established and maintained by maladaptive thoughts and behaviors.
The development of CBT has come in three distinct movements. The first wave of CBT, called Behavioral Therapy, applied principles of classical conditioning and operant learning to bring forth overt behavioral change.
The second wave combines Behavioral and Cognitive Therapy, which emphasizes information processing and the role that maladaptive thinking has on emotional and behavioral patterns in order to incite change - this approach is considered “classic CBT.”
The third wave focuses keenly on clients’ relationship with their thoughts and feelings more so than the content of either in order to initiate change. As such, CBT is considered a therapy itself and also an umbrella term for all of the therapies that have come forth during each wave.
CBT is in part based on constructivist theory, meaning that individuals are responsible for their own reality.
Recognizing one’s responsibility naturally implies an ability to make efforts toward beneficial changes. The Greek Stoic philosopher, Epictetus said, “It is not what happens to you but how you react to it that matters."
CBT does not discount the impact of biology and external stressors on mental health, though it maintains that thoughts, feelings and behaviors are interrelated, influence each other, and can be changed by the individual.
In CBT, clients are also responsible for doing the work necessary in therapy to create the changes they seek; they are not merely a passive receiver of the therapist's work.
Classic CBT was first presented to the field of psychotherapy by Albert Ellis, Ph.D., in 1955 in the form of what is now called REBT (Rational Emotive Behavior Therapy) (back then it was called Rational Therapy), and by Aaron T. Beck, MD in the early 1960s as CT (Cognitive Therapy).
Aaron T. Beck is often considered the “Father” of CBT, while Albert Ellis is known as the “Grandfather” of CBT. Both were particularly interested in an alternative to psychoanalysis, which was the most widely accepted therapy at the time.
At present, CBT is widely recognized as the set of psychological treatments with the most extensive empirical support and research contributions over the past six decades from around the world continue to further the development of CBT as a whole through the present day.
3. How hands on is the therapist in a CBT-style therapy?
CBT is a very hands-on style of treatment for both therapist and client. The therapist takes an active role in the client’s progress and provides a safe and open space to address concerns and help direct the work toward the client’s desired outcomes.
For example, it's customary that an agenda be mutually agreed upon at the beginning of each meeting to respect the client's objective(s) for that particular session and remain productive in that vein. The therapist may offer handouts, worksheets, and other projects that the client may choose to participate in during or outside of session to enhance the therapeutic process.
4. Please share a real but anonymized example of what CBT looks like in the room.
J came into session wanting to change his habit of staying late at work every night, never leaving on time, and thus neglecting personal wants and needs to relax, socialize, and sleep, which was contributing to chronic stomach aches, and his boyfriend was frustrated that he never seemed to have any free time.
This pattern related to his overall problem with anxiety, which he has sought treatment for.
Together, we identified the trigger for his self-defeating behavior. There were, in fact, a lot of tasks at work, but his colleagues were able to leave on time with the same workload.
Cognitive impairment and learning disabilities had already been ruled out.
We explored which feelings and subsequent reactions he had about his work. He stated that he felt anxious, had a hard time concentrating, and was easily distracted.
As a result of feeling anxious, we noted that his predictions for the future seemed very doom-and-gloom.
We could see why was he was staying late every night, given that he could hardly concentrate and was consumed with worry. He could barely focus on his work this way.
Next, we uncovered the harmful beliefs he held about work that contributed to his anxiety and made him less efficient. With the help of directive questioning, he recognized that he’d been telling himself he absolutely must be recognized as the best employee, couldn’t bear to be seen as anything less, and if others viewed him as anything less, it would mean he’s no good at all.
I then helped J assess the outcomes he created for himself by living with these chosen ideas about work and self-worth. He could see that these rigid and extreme beliefs had gotten him into a pattern of self-defeat. He had been so fearful of failing to be “the best” that he was burnt out and working below his potential due to the stress and anxiety symptoms he created.
Once he realized his predominant thoughts have harmed his ability to do well at work and enjoy his free time, we challenged those thoughts further to break down his attachment to them. Through various techniques, I posed inquiries for him to consider and in doing so he realized that his attitudes had been unhelpful, illogical, and untrue.
Within this process, I modeled and taught him these inquiry skills so that he could use them himself in the future.
With my help, as needed, he developed a new attitude: “I prefer to impress people at work so I'll work within reason to do so, but there’s no law of the universe that I MUST be considered the best employee. I can stand it if I’m not seen that way and can work to improve if I choose. Whether people at work think I'm the best or not, my value and worthiness will not change. I can seek to improve at work to enhance my experience there, but it will never be a measure of my worth as a person because my worth is inherent.”
He made the connection that with this new mindset he’d feel healthy concern about getting his work done and have the motivation to do his best without getting distracted nearly as often. He would be able to leave his job on-time as his colleagues do.
His outlook on the future would be realistic, and he’d put the appropriate amount of time and energy into his work and still have time for the other important things in life. The anxiety and stomach aches would be replaced with healthy concern and symptom alleviation.
Once he had this adaptive new attitude top-of-mind, we collaboratively developed homework to help him strengthen his conviction in this rational attitude. We decided that he’d share the new rational belief with his boyfriend to strengthen his understanding of it, as well as write it out and respond to any arguments he had of against it to address reservations about this new point of view. In the next session, we started by following up on how the homework went.
5. Please share three or more issue areas CBT is particularly helpful in working through. Why do you think that is?
CBT is effective in treating the vast majority of diagnosable mental health disorders as well as problems such as low self-esteem, assertiveness issues, feeling stuck, indecisiveness, relationship problems, self-control, anger, hopelessness, and more. CBT is so effective in treating a wide range of problems because it targets the client’s thoughts and behaviors in the here-and-now as the primary means for change.
6. How long does a CBT treatment generally last?
There are no one-size fits all in therapy. The length of treatment, assuming there aren’t external factors limiting the number of sessions, really depends on the client’s goals, the severity of their problems, and their commitment to the work inside and outside of meetings.
CBT doesn’t have a prescribed number of sessions, although it is often chosen when there are factors which limit the number of sessions a client will attend.
CBT is empirically supported as a brief treatment method for measurable change. The Albert Ellis Institute for cognitive behavioral and rational emotive behavioral therapy describes CB/REBT as "short-term therapy with long-term results," because this method of treatment has been developed to help clients become their own therapist over time.
7. Are there certain personality types that would work especially well with CBT?
I think there’s a form of CBT for anyone looking to address their troubles actively. CBT is particularly good for those looking to be challenged in the therapeutic space.
When I first meet clients, many of them tell me, “I want someone to call me out on my shit.”
CBT therapists are trained to therapeutically call you out on your shit with compassion, empathy, and unconditional acceptance. A CBT therapist can help you think critically about your patterns without judging or criticizing you.
8. Are there certain personality types that may not enjoy working with CBT?
I think some types of CBT may work better for some than others. CBT may not be the best fit for someone looking to gain insight into their past without any particular goals for treatment outcomes.
9. How do you know if CBT is working for someone? How do you know if it’s not?
Many therapists help clients develop Specific, Measurable, Achievable, Realistic, and Time-specific) (SMART) short-term objectives and long-term goals for therapy so we can measure progress over time, as well as adjust or change goals as needed.
Rather than something difficult to measure, such as “feeling less anxious,” we would, for instance, reduce panic attacks to once per month or less, and sleep a full eight hours every night at least six nights a week for at least three months, etc.
As objectives are met, we develop new ones to progress toward long-term goals. If objectives aren’t being met, we reflect on why and problem solve from there. SMART goals help therapy stay on track, and the client and therapist have a good sense of how things are going.
10. How should a therapy-goer prepare for a CBT session? What type of work is entailed?
You can start CBT wherever you are. Often it’s hard to identify what’s wrong or what you want to achieve in therapy. You don’t need to know the answers to these questions to begin, but your therapist will probably ask what you hope to gain from treatment. If the first step in therapy is figuring out what that is, it’s 100% okay. A CBT therapist can help you better clarify what you might want to work toward.
Once the therapeutic process begins, clients usually benefit most when they are engaged during and between sessions. The best way to make progress is to implement your therapeutic gains into everyday life. A therapy session is usually 45 minutes, so what you do with the other 10035 minutes of the week counts for a lot!
11. What is your favorite thing about CBT?
I love that my clients gain a healthier mindset to take with them beyond therapy. They have skills, tools, and takeaways that they can apply to any problem they’re faced with down the road.
Since CBT is goal-oriented, it’s great to rejoice with my clients in the progress they make. I also get satisfaction in supporting and helping my clients get back on track when they’re not making the progress they want.
Backsliding is normal in any form of therapy, so I love using those experiences as an opportunity to learn about adaptability and resilience. These are lesson my clients can use to their benefit the next time the road gets rocky.
12. What advice might you give to a therapy-seeker wondering if CBT is right for them?
If you’re interested CBT, I recommend researching a well-trained therapist with whom you think you could feel comfortable with and set up a consultation.
Most therapists, including myself, offer a free consultation for anyone curious about working together.
It’s important to work with someone who engages in professional training and support, but the therapeutic relationship is just as important, which is why taking the time to speak over the phone first can help you decide.
According to research done by APA’s Society of Clinical Psychology, “the therapy relationship accounts for why clients improve (or fail to improve) at least as much as the particular treatment method.”
Want to know if CBT is right for you or if we’re a good fit? Book a free consultation with me to learn more.