You’ve probably heard of cognitive behavioral therapy (CBT), the evidence-based psychotherapy treatment method focused on changing negative thoughts and behaviors. It seems to be mentioned in nearly every self-help article online: Sleep problems? Try CBT. Childhood trauma? CBT may help. Anxiety, depression, low self-esteem, fear of flying, hangnails? CBT is the answer for you.
Basically, there’s a good chance you’ve either received CBT or know someone who has. So what is it? Does it really alleviate psychological distress, and if so, how? How much does it cost, and can you just use the techniques on your own? These kinds of details can be a mystery to the general public. Lucky for you, I’m a clinical psychologist who uses CBT in my practice, so I should be able to answer most of the questions you have about it. Let’s dig into them one at a time.
CBT is one of scores of treatment methods used in psychotherapy. It’s based on the assumption that many of life’s problems stem from faulty thoughts (that’s where “cognitive” comes from) and behaviors. By intentionally shifting them toward healthier, more productive goals, we can alleviate distress. In practice, cognitive behavioral therapy generally consists of identifying the problematic thoughts and behaviors and replacing them with healthier responses.
For example, say Jane Doe is anxious in social situations and has started to avoid gatherings in favor of isolating evenings at home. A CBT therapist may educate her about the fear response that is being irrationally triggered, teach her how to shift her thoughts and relax her body, and develop an action plan to help her remain calm while engaging in the party this weekend. Next week, they’ll evaluate what worked and what didn’t, and tweak their methods until Jane can comfortably socialize.
CBT is used for anything from phobias, anxiety, depression, trauma, self-esteem issues, and ADHD, to relational problems like poor communication or unrealistic expectations of your partner. Basically, if it’s an issue that involves thoughts and behaviors (which covers a lot of ground), CBT has a treatment approach for that.
Is it right for you? That’s a difficult question. Do your problems concern how you think and behave? For example, are you ruminating about a past breakup or finding yourself mindlessly shopping online? If so, then yes, you could probably benefit from CBT. If you are more concerned about your purpose or meaning in life, or about what moments from your past color who you are today, there may be other approaches that fit better for you (and we’ll get to that in question #9).
One of the reasons CBT is so well-known and widely used is because it has been studied so extensively. It is a good modality to study because it emphasizes brief, direct, solution-oriented interventions. In other words, the aim is to produce clear, measurable changes in thoughts and behaviors, which is a goldmine for researchers. It also means you get to see quick results.
I asked Martin Hsia, Psy.D., a certified CBT psychologist in Glendale, California about how he uses it in his practice. “Since a high percentage of people we see in our practice are dealing with some form of anxiety (social anxiety, health or illness anxiety, OCD, panic, etc.), being able to gently challenge people to face their fears and develop new ways of relating to their own thoughts is a central part of the work,” he says. “CBT gives us the tools to encourage people to do something highly unpleasant: confront the things they have been avoiding.”
CBT is a form of psychotherapy, so you can expect the early sessions to be what you would see in any initial therapy sessions: discussing payment information and the cancellation policy, your goals for therapy, your history, and a review of your problems. After that, you’ll talk about the struggles you encounter and try to formulate the most effective response together.
Essentially, the client brings in the problems they’d like to overcome or the situations they find stressful, and the therapist and client work together to create an action plan. An action plan means they identify the problematic thoughts or behaviors, find a way to change them, and develop a strategy to implement this change in the coming week. This is where “homework” comes in.
CBT is focused on providing a quick (8 to 12 sessions, which is quick by therapy standards) and effective reduction of symptoms, which is best done by applying the techniques throughout the week, not just during the therapy session. Typical homework might include relaxation exercises, keeping a journal of thoughts and emotions throughout the week, using worksheets that target a specific area of growth, reading a book that applies to your issues, or seeking out situations to apply your new approach. For example, Jane may want to keep an eye out for meet-up events that challenge her to overcome her fears while she applies her new relaxation techniques.
Another example: Let’s say a major factor in John Doe’s depression is his negative internal self-talk—he constantly belittles and berates himself on a loop. John and his CBT therapist may discuss a technique called “thought stopping” where he abruptly disrupts the flow of negative thoughts by yelling (in his mind) “Stop!” as he redirects his thoughts to something more positive like an affirmation or a meditation app. Homework may involve practicing this technique at least once every day until the next session. John and his therapist will debrief in the next session, evaluate what worked and what didn’t, and tweak the process for the following week.
One of the highlights of CBT is that it is focused on eliminating symptoms as quickly as possible, typically in a few weeks to a few months. Of course, people rarely have only a single issue to work on in therapy, so this length depends on the number and severity of the issues, but brevity is key to this approach.
This brings up one of the major differences between CBT and many other forms of therapy. According to Donald Meichenbaum, one of the founders of CBT, “[We ask] what and how questions. Why questions are not very productive.” While other treatment approaches spend a great deal of time digging deep and asking why you feel depressed, anxious, or have low self-esteem, CBT sticks to the current thoughts and behaviors. Rather than examining why you are afraid of snakes, CBT focuses on helping you reduce your fear. While some people are content with reducing their symptoms, others want to know why they exist in the first place. For them, deeper approaches like psychodynamic therapy may be more satisfying.
Have you ever kept a gratitude journal? What about monitoring your donut intake? Have you tracked your daily steps or monitored your sleep? Then you’re already applying some of the principles of CBT in your everyday life. You can find many of CBT’s techniques in books like David Burns’s Feeling Good or Edmund Bourne’s Anxiety and Phobia Workbook, online, or in popular apps like Headspace and Happify. But for a course of CBT tailored to you and your issues, a period of time in structured therapy is still the best approach.
CBT is psychotherapy, so if your insurance covers psychotherapy or behavioral medicine, it should cover most, if not all, of your CBT therapy. If you’re paying out of pocket, CBT costs range from free or on a sliding scaled at some community clinics, to $200+ per session in a private practice. Again, the length of time someone spends in treatment is generally less than other treatment approaches, so it may be cheaper in the long run. You can search for a therapist who practices CBT and fits your budget on a therapist finder website like Psychology Today or GoodTherapy.
Some clients may feel that they want therapy to be a place where they come and process their experiences with some gentle facilitation by their therapist. Their main goal may not be dealing with a specific symptom or problematic habit, but more about general growth and a long-term relationship with a therapist. Maybe they want to explore their memories, dreams, and early relationships with guidance from their therapist. Given that CBT can be a more direct and practical style of therapy, it may not feel helpful for someone seeking that kind of deep, relational work. Having said that, many skilled therapists who practice CBT are very flexible with their approach, and can adjust to meet the needs of a variety of clients.
CBT is not without its critiques, as even Dr. Hsia admits. “Fair criticisms of CBT highlight its ‘one-size-fits-all’ assumptions about what helps people get better,” he says. Again, CBT focuses on symptoms instead of those symptoms’ deeper roots, and some psychologists who feel the deeper roots are essential would consider CBT short-sighted. In the end, you need to find out what works best for you, and that might take some trial and error.
You may find it most helpful to talk to your therapist (or potential therapist) about what you’re seeking help for and ask them how they would approach the treatment. Whether you receive CBT treatment or another method, the most important thing is that you feel a safe, trusting connection with your therapist and that the treatment makes sense to you.
Ryan Howes, Ph.D., ABPP, is a licensed clinical therapist who practices in Pasadena, California.
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