Cognitive-Behavioral Therapy

Learning Objectives

  • Describe how cognitive and cognitive-behavioral therapy are used as treatment methods
  • Describe systematic desensitization

Psychotherapy: Cognitive and Cognitive-Behavioral Therapy

Cognitive therapy is a form of psychotherapy that focuses on how a person’s thoughts lead to feelings of distress. The idea behind cognitive therapy is that how you think determines how you feel and act. Cognitive therapists help their clients change dysfunctional thoughts in order to relieve distress. They help a client see how they misinterpret a situation (cognitive distortion). For example, a client may overgeneralize. Because Ray failed one test in his Psychology 101 course, he feels he is stupid and worthless. These thoughts then cause his mood to worsen. Therapists also help clients recognize when they blow things out of proportion. Because Ray failed his Psychology 101 test, he has concluded that he’s going to fail the entire course and probably flunk out of college altogether. These errors in thinking have contributed to Ray’s feelings of distress. His therapist will help him challenge these irrational beliefs, focus on their illogical basis, and correct them with more logical and rational thoughts and beliefs.

Cognitive therapy was developed by psychiatrist Aaron Beck in the 1960s. His initial focus was on depression and how a client’s self-defeating attitude served to maintain a depression despite positive factors in her life (Beck, Rush, Shaw, & Emery, 1979)(Figure 1). Through questioning, a cognitive therapist can help a client recognize dysfunctional ideas, challenge catastrophizing thoughts about themselves and their situations, and find a more positive way to view things (Beck, 2011).

One of the first forms of cognitive-behavior therapy was rational emotive therapy (RET), which was founded by Albert Ellis and grew out of his dislike of Freudian psychoanalysis (Daniel, n.d.). Behaviorists such as Joseph Wolpe also influenced Ellis’s therapeutic approach (National Association of Cognitive-Behavioral Therapists, 2009). During the 1980s and 1990s, cognitive and behavioral techniques were merged into cognitive-behavioral therapy. Pivotal to this merging was the successful development of treatments for panic disorder by David M. Clark in the UK and David H. Barlow in the U.S. Over time, cognitive-behavioral therapy came to be known not only as a therapy, but as an umbrella category for all cognitive-based psychotherapies.

This graphic depicts two three-box flowcharts showing reactions to failing a test. The first flowchart flows from “Failed test” to “Internal beliefs: I’m worthless and stupid” to “Depression.” The second flowchart flows from “Failed test” to “Internal beliefs: I’m smart, but I didn’t study for this test. I can do better.” to “No depression.”

Figure 1. Your emotional reactions are the result of your thoughts about the situation rather than the situation itself. For instance, if you consistently interpret events and emotions around the themes of loss and defeat, then you are likely to be depressed. Through therapy, you can learn more logical ways to interpret situations.

Link to Learning

View a brief video in which Judith Beck, psychologist and daughter of Aaron Beck, talks about cognitive therapy and conducts a session with a client.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) helps clients examine how their thoughts affect their behavior. It aims to change cognitive distortions and self-defeating behaviors. For example, if it’s your first time meeting new people, you may have the automatic thought, “These people won’t like me because I have nothing interesting to share.” That thought itself is not what’s troublesome; the appraisal (or evaluation) that it might have merit is what’s troublesome. The goal of CBT is to help people make adaptive, instead of maladaptive, appraisals (e.g., “I do know interesting things!”). This technique of reappraisal, or cognitive restructuring, is a fundamental aspect of CBT. With cognitive restructuring, it is the therapist’s job to help point out when a person has an inaccurate or maladaptive thought, so that the patient can either eliminate it or modify it to be more adaptive. In essence, this approach is designed to change the way people think as well as how they act.

In total, hundreds of studies have shown the effectiveness of cognitive-behavioral therapy in the treatment of numerous psychological disorders such as depression, PTSD, anxiety disorders, eating disorders, bipolar disorder, and substance abuse (Beck Institute for Cognitive Behavior Therapy, n.d.). For example, CBT has been found to be effective in decreasing levels of hopelessness and suicidal thoughts in previously suicidal teenagers (Alavi, Sharifi, Ghanizadeh, & Dehbozorgi, 2013). Cognitive-behavioral therapy has also been effective in reducing PTSD in specific populations, such as transit workers (Lowinger & Rombom, 2012).

Cognitive-behavioral therapy aims to change cognitive distortions and self-defeating behaviors using techniques like the ABC model. With this model, there is an Action (sometimes called an activating event), the Belief about the event, and the Consequences of this belief. Let’s say, Jon and Joe both go to a party. Jon and Joe each have met a young woman at the party: Jon is talking with Megan most of the party, and Joe is talking with Amanda. At the end of the party, Jon asks Megan for her phone number and Joe asks Amanda. Megan tells Jon she would rather not give him her number, and Amanda tells Joe the same thing. Both Jon and Joe are surprised, as they thought things were going well. What can Jon and Joe tell themselves about why the women were not interested? Let’s say Jon tells himself he is a loser, or is ugly, or “has no game.” Jon then gets depressed and decides not to go to another party, which starts a cycle that keeps him depressed. Joe tells himself that he had bad breath, goes out and buys a new toothbrush, goes to another party, and meets someone new.

Jon’s belief about what happened results in a consequence of further depression, whereas Joe’s belief does not. Jon is internalizing the attribution or reason for the rebuffs, which triggers his depression. On the other hand, Joe is externalizing the cause, so his thinking does not contribute to feelings of depression. Cognitive-behavioral therapy examines specific maladaptive and automatic thoughts and cognitive distortions. Some examples of cognitive distortions are all-or-nothing thinking, overgeneralization, and jumping to conclusions. In overgeneralization, someone takes a small situation and makes it huge—for example, instead of saying, “This particular woman was not interested in me,” the man says, “I am ugly, a loser, and no one is ever going to be interested in me.”

All or nothing thinking, which is a common type of cognitive distortion for people suffering from depression, reflects extremes. In other words, everything is black or white. After being turned down for a date, Jon begins to think, “No woman will ever go out with me. I’m going to be alone forever.” He begins to feel anxious and sad as he contemplates his future.

The third kind of distortion involves jumping to conclusions—assuming that people are thinking negatively about you or reacting negatively to you, even though there is no evidence. Consider the example of Savannah and Hillaire, who recently met at a party. They have a lot in common, and Savannah thinks they could become friends. She calls Hillaire to invite her for coffee. Since Hillaire doesn’t answer, Savannah leaves her a message. Several days go by and Savannah never hears back from her potential new friend. Maybe Hillaire never received the message because she lost her phone or she is too busy to return the phone call. But if Savannah believes that Hillaire didn’t like Savannah or didn’t want to be her friend, she is demonstrating the cognitive distortion of jumping to conclusions.

How effective is CBT? One client said this about his cognitive-behavioral therapy:

I have had many painful episodes of depression in my life, and this has had a negative effect on my career and has put considerable strain on my friends and family. The treatments I have received, such as taking antidepressants and psychodynamic counseling, have helped [me] to cope with the symptoms and to get some insights into the roots of my problems. CBT has been by far the most useful approach I have found in tackling these mood problems. It has raised my awareness of how my thoughts impact on my moods. How the way I think about myself, about others and about the world can lead me into depression. It is a practical approach, which does not dwell so much on childhood experiences, whilst acknowledging that it was then that these patterns were learned. It looks at what is happening now, and gives tools to manage these moods on a daily basis. (Martin, 2007, n.p.)

Link to Learning

Watch this video clip for an overview of CBT:

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Behavior Therapy: How Does it Work?
Smiling picture of a college student with a pen in her mouth.

Meet Miriam. She is smart, ambitious, creative, and full of energy. She is studying at a university, majoring in business. During the next few years, after she graduates, she wants to live in interesting places and get solid training and experience with a good corporation. Her dream is to start her own company, to be her own boss, and to do things that she can take pride in. For her, financial success and doing something worthwhile must go hand-in-hand.

But Miriam has a secret. She is terrified of speaking in front of people who are not her close friends. She has fought these fears for a long time, but she has never been able to conquer them. She is also aware of the fact that she will need to be able to speak to strangers comfortably and convincingly if she is going to meet her goals in business.

Now that you and your client have agreed upon your goals, it is time to choose a particular technique for the therapy. As a behavioral therapist, you are looking for a method to allow Miriam to learn a new response to the thought of public speaking. Now the idea terrifies her. After therapy is over, she should no longer be terrified and she may even look forward to the opportunity to speak in front of other people.

You know that everyone is not the same and different problems may call for different approaches to therapy. For these reasons, you have been trained in a variety of techniques that you can use to customize Miriam’s therapy to meet her particular needs. It is time to decide how you are going to help Miriam.

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Systematic desensitization works by gradually—step-by-step—exposing the person to situations that are increasingly more anxiety-producing. This is called “progressive exposure.” By learning to cope with anxiety with less-threatening situations first, the person is better prepared to handle the more-threatening situations. Even more important for treatment, the mind learns that nothing horrible happens. This retraining of the subconscious mind means that the situation actually becomes less threatening.

Same picture of the college student, Miriam, looking confused or frustrated while looking at her notebook.

The first steps in systematic desensitization is the development of a “hierarchy of fears.” This simply means that you must help your Miriam create a list of situations related to her fear of public speaking. Then you create a hierarchy. This means that you have her organize the situations from the least frightening to the most frightening.

For the next step in this exercise, you will need to take on Miriam’s role as the client. Imagine that you have developed a list of frightening situations, from ones that make you only slightly uncomfortable to ones that nearly make you sick with anxiety.

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Remember that systematic desensitization works by putting the person in a series of situations. The early ones are not threatening or are only mildly threatening. However, as soon as your client learns to cope with each situation, you start working on the next most frightening situation.

So we’re ready to start, right? Wrong!

Behavioral therapy teaches the client to cope with an anxiety-producing situation by replacing fear with an alternative response. A common alternative response is relaxation. This idea is that fear and anxiety cannot coexist with relaxation—if you are relaxed, you can’t be fully afraid.

However, most people are not very good at relaxing on command. So the behavioral therapist will teach the client how to relax effectively. The techniques are ones often used in meditation—slow breathing and focus on positive thoughts. Psychologist Kevin Arnold explains a deep breathing technique in this video.

Miriam’s Treatment

Miriam is an imaginary person, but behavioral therapy is used by thousands of therapist with their clients every day. Review the following table to discover how Miriam’s therapy progressed. Her story is based on a fairly typical series of therapy sessions, though please understand that each person’s course of therapy is unique.

Miriam’s therapy: Preparation Prior to starting progressive exposure, Miriam created her hierarchy of fears. She spent several two session working on relaxation. She practiced relaxation at home several times a day until she and you, her therapist, agreed that she was ready to start treatment.
Miriam’s therapy: Exposure Session 1 The bottom (lowest anxiety) of Miriam’s fear hierarchy was chatting with friends about everyday topics. When asked to rate the fear level associated with doing this on a 1 to 10 scale, Miriam said 1: No fear at all.

Miriam brought two friends with her to the therapy session today. You had them sit in a comfortable part of your office, drinking tea and chatting for 15 minutes. Afterwards Miriam reported her fear level during the chat as a 1 on a ten-point scale: no fear.

You then had her sit in a comfortable chair and think about giving a talk about the challenges of her job to a small, friendly audience. At the beginning of this task, she rated her anxiety as 3 on a 10-point scale. As she thought about it—with helpful suggestions from you—she also relaxed, using her relaxation training. After about 10 minutes, she reported her anxiety had dropped to 1, the lowest level of anxiety on your scale.

You gave Miriam “homework”—to repeat this exercise twice a day until the next session.

Miriam’s therapy: Exposure Session 2 At the beginning of today’s session, you had Miriam repeat the task from the previous session of thinking about talking about her job to a small, friendly group. At the beginning she rated her fear at 2, but it dropped to 1 within a few minutes.

Now you took Miriam to the next level. You had her imagine telling a large audience of company executives about some technical problem she was working on at her job. At the beginning, just thinking about doing this led to a fear level of 5. After 10 minutes, her fear level dropped to 2. You repeated the exercise with a different topic and a different group, with similar results. Relaxation was practiced throughout the session.

You gave Miriam homework again—to practice a similar situation at home.

Miriam’s therapy: Exposure Session 3 You started this situation with a new scenario similar to the one Miriam did in the last session and practiced at home. She was quickly able to drop her anxiety level to 1.

You had a professional photography group create a video of someone very similar in appearance and manner to Miriam giving a talk in from of a small friendly audience on a topic similar to one Miriam might give. You asked her to watch this video and imagine herself in the place of the real speaker. She rated this a 6 on the anxiety scale. Over several repetitions, her rating dropped to 2.

For homework, Miriam watched the video several times a day. You instructed her in ways to make the video seem MORE REAL, so she could really feel the anxiety of being in front of people.

Miriam’s therapy: Exposure Session 4 You have had Miriam arrange to give a talk NEXT SESSION to a small group of Miriam’s co-workers. You also had Miriam prepare the talk. Today you practiced the talk with her. At the start of the practice session, with only you there, Miriam rated her anxiety level at 9 out of 10. Over the course of the hour, her anxiety level dropped to 5.

Her homework was to continue to practice the talk and to work on relaxation.

Miriam’s therapy: Exposure Session 5 Today, Miriam gave the talk to the small group. Her anxiety rating before she went in front of them was 10. Except for a little stumbling at the start, the 20-minute presentation went well. Miriam reported an anxiety level of 4 after the talk.
We’ll skip a few sessions. We hope you have the basic idea.
Miriam’s therapy: Exposure Session 5 In this last session, you have arranged for Miriam to be the introductory speaker at a literacy tutoring volunteer organization nearby. Miriam has done a small amount of volunteer work with the organization, but she knows very little about it. With the help of the staff, she prepares a talk during the week before this session.

The audience is composed of 45 people, all interested in doing literacy tutoring, who have come to the literacy center for an information session. Miriam knows none of them and none of them has ever heard of her.

Miriam’s introductory comments take about 15 minutes. She rates her anxiety level before going out at 8. After the talk, she rates her anxiety at 2. In fact, she said it was almost fun.

After Therapy Miriam continues to see you for a few more sessions. You give her additional homework and you help her develop a plan that includes arranging to give professional presentations for her job and continuing to give talks at the literacy volunteer organization. Miriam reports that none of these ideas create an anxiety level above 3 when she thinks about doing them.

You just learned about Systematic Desensitization, a form of exposure therapy. Flooding is another type of exposure therapy. To understand how it works, let’s review a few points from Systematic Desensitization.

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In flooding therapy, you would skip the earliest situations described in systematic desensitization and you would move directly to highly threatening situations. Right after Miriam had mastered relaxation, your first session would require Miriam to give an actual talk. You would probably not start with the most extreme situation, but your goal would be to start Miriam in situations that she would immediately rate as 9 or 10 on the anxiety scale.

Flooding has the potential to be more traumatic for Miriam (for your client), so it must be arranged carefully. But the same principles of learning work for flooding that work for systematic desensitization:

  • The person consciously works to replace anxiety and fear with relaxation.
  • The unconscious parts of the mind learn that the situation does not result in horrible outcomes. New expectations replace old fears.
  • Learning does not just happen immediately. Homework and repeated practice reinforce the new positive response to situations that once produced fear.

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cognitive-behavioral therapy: form of psychotherapy that aims to change cognitive distortions and self-defeating behaviors
cognitive therapy: form of psychotherapy that focuses on how a person’s thoughts lead to feelings of distress, with the aim of helping them change these irrational thoughts
rational emotive therapy (RET): form of cognitive-behavioral therapy