Psychotherapy: Cognitive and Cognitive-Behavioral Therapy (CBT)

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 general psychology course, he feels he is stupid and worthless. These thoughts then cause his mood to worsen and may lead to procrastination or distancing himself from the class. Therapists also help clients recognize when they blow things out of proportion. Because Ray failed his psychology 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.

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 and adaptive ways to interpret situations.

Figure 2. In CBT, therapists seek to help clients adopt more adaptive thought patterns and behaviors.

Cognitive-behavioral therapy (CBT) is a very large group of psychotherapeutic approaches that help 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 cognitive-behavioral therapy (CBT) is to help people make adaptive, instead of maladaptive, appraisals (e.g., “I do know some interesting things!”). This technique of reappraisal, or cognitive restructuring, is fundamental to cognitive-behavioral therapy (CBT). With cognitive restructuring, it is the therapist’s job to help point out when a person has an inaccurate or a 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 and feel as well as how they act.

Contrary to psychoanalytic and psychodynamic approaches, cognitive therapy and CBT are present-focused; they are aimed at understanding the situations the client is in, their current thoughts and beliefs, and working with them to practice and replace dysfunctional thinking with more healthy thought patterns and behaviors. CBT therapists do have an interest in their client’s previous history, mostly as a way to better understand the events that may have led to current patterns of thinking and for understanding how long the client has been experiencing these negative emotions and symptoms. CBT also tends to be shorter in duration than older forms of therapy, often achieving significant benefits to clients in 12–16 sessions or less (depending on the nature of the disorder and severity of symptoms) which makes it equally or more cost-effective than other forms of treatment, including use of long-term medications.

Another distinctive trait of almost all forms of CBT is that sessions are very interactive between the client and the therapist, and treatment involves between-session homework assignments. For example, the therapist may give a patient who compulsively washes her hands for hours a day a worksheet to take home; on this worksheet, the woman is to write down every time she feels the urge to wash her hands, what thoughts she is experiencing at the time, how she deals with the urge, and what behavior she uses to replace that urge. When the patient has her next therapy session, she and the therapist review her homework together as a starting point and an opportunity to help her practice and rehearse new thinking and evaluate her success with behavior change. Given the supportive and interactive nature of CBT, the alliance and relationship between therapist and client is very important.

There are different protocols for delivering cognitive behavioral therapy, with important similarities among them. Use of the term CBT may refer to different interventions, including “self-instructions (e.g. distraction, imagery, motivational self-talk), relaxation and/or biofeedback methods, development of adaptive coping strategies (e.g. minimizing negative or self-defeating thoughts), changing maladaptive beliefs about pain, and goal setting”^[1]. Treatment is sometimes “manualized” (as in a manual/book), with brief, direct, and time-limited treatments for specific psychological disorders that are technique-driven. CBT is used in both individual and group settings, and the techniques are often adapted for self-help applications. Some clinicians and researchers are more cognitively oriented (e.g., cognitive restructuring), while others are more behaviorally oriented (e.g., live exposure therapy). Interventions such as imaginal exposure therapy combine both approaches.

Persons with medical conditions may also benefit from CBT; evidence supports its use with chronic back pain, fibromyalgia, post spinal cord injuries, insomnia, and pain management in a variety of conditions including breast cancer.

CBT may also be delivered in conjunction with a variety of diverse but related techniques including exposure therapy, stress inoculation, cognitive processing therapy, cognitive therapy, relaxation training, dialectical behavior therapy, and acceptance and commitment therapy. It is therefore a fairly adaptive form of treatment that maintains core principles but is useful and applicable to many specific situations.

One benefit of CBT is that it is an intuitive treatment that makes logical sense to patients. CBT can also be adapted to suit the needs of many different populations. One disadvantage, however, is that CBT does involve significant effort on the patient’s part because the patient is an active participant in treatment both in sessions and through between-session homework. The greatest strength of CBT is the abundance of empirical support for its effectiveness. Studies have consistently found CBT to be equally or more effective than other forms of treatment, including medication and other therapies (Butler, Chapman, Forman, & Beck, 2006; Hofmann et al., 2012). For this reason, CBT is considered a first-line treatment for many mental disorders. In depression, for example, CBT has been shown to have the same or better effectiveness than antidepressant medications, but with significantly lower rates of relapse after treatment is completed. The use of CBT in anxiety disorders rather than use of benzodiazepine medications may result in significant benefit without the risk of dependence on the medications and/or subsequent withdrawal and relapse effects.

One client said the following 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.)

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).