A Complete Guide to

Cognitive Behavioural Therapy

Written by OLIVIA MOHTADY
Medically reviewed by Dr. Maroof Ahmed, MD on November 23, 2018

Cognitive Behavioural Therapy (or CBT) has become widely used in the growing vocabulary of terms surrounding well-being and health. There is a strong evidence base for the credibility of CBT in the context of mental health. And yet many of us have not been well informed about what exactly CBT is and when it might be useful to us. This is unfortunate, as CBT skills could be helpful to many of us in addressing the fundamental difficulties that come with being human in the modern world.

What is CBT?

CBT (or cognitive behavioral therapy) is an intervention that was initially developed by American psychologist Aaron Beck for the treatment of depression, back in the 1960s. It has since been adapted for a number of difficulties around mood and motivation and other conditions. Prime examples of targeted CBT interventions include those helping individuals overcome addiction to smoking, drugs and alcohol but CBT can also help other conditions such as: Eating Disorders, Obsessive Compulsive Disorder (OCD) and Bipolar Disorder.

The main principles of CBT are that thought patterns, feelings and behavior are all constantly interacting with one another. Sometimes, that interaction can become unhelpful or distressing for a person. This is often the case when negative thoughts begin to dominate how that person feels or behaves. Negative feelings and destructive behaviors may then reinforce negative thoughts.

The main principles of CBT are that thought patterns, feelings and behavior are all constantly interacting with one another.

CBT techniques involve recognising and addressing this interaction to enable individuals to overcome specific problems.

Take depression: a common problem involving pervasive feelings of sadness and hopelessness about the self, world and future. Beck identified the ways in which the symptoms of depression might reinforce one another, and ways to undo that vicious cycle. This logic has been similarly applied to cycles of addiction and low motivation.

The behavioral bit

Depression is often characterised by inactivity. It can feel like the whole world (and your thoughts about it) are weighing you down, making simple tasks impossible. Many people with serious depression struggle to even get out of bed in the morning.

Behavior therapy for depression, therefore, involves encouraging a person to engage in more activity. These activities might include exercising, socialising and work. A behavioral activation therapist will help a client schedule events in their diary on a weekly basis.

The theory behind these behavioral techniques is that activity will have a positive effect on emotions and thinking processes by increasing daily rewards for the individual. This will, in turn, increase a person’s motivation for completing further healthy behaviors.

For example, they might find spending more time with friends cheers them up and gets them invited to additional fun and social events. Going to the gym might increase energy levels to allow the person to get more done at work, which in turn boosts self-esteem.

The basic principles of increasing activity to increase reward and motivation can be useful to anyone, with or without depression. Behavior therapy can be particularly helpful for breaking bad habits and addictions. The more we engage with behaviors that are consistent with our goals, the more we begin to believe we are healthy people and continue to live by that standard.

Behavioral techniques on their own can be very challenging. This especially depends on the extent to which negative thoughts and beliefs are getting in someone’s way of behavior change. However, behavioral activation can be a fantastic start to changing habits.

The cognitive bit

Cognitive Behavior Therapy (CBT) goes one step further than behavior therapy by helping a person target the daily automatic thoughts that are weighing them down so much. For somebody with depression, thoughts may include negative beliefs about the self (‘I am stupid’), the world (‘nobody likes me’) and future (‘I will never succeed’).

For somebody with an addiction, thought patterns might include beliefs about the self as well as the function of the specific substance they are addicted to. Examples might include: ‘I need alcohol to get me through the day’, ‘drugs control my life’ or ‘I will never be able to give up smoking’.

You will notice that all these thoughts, regardless of the issue, are very black-and-white. Cognitive behavior therapy, therefore, involves questioning the evidence for and against these thoughts. This gives the person a more objective sense of themselves and their difficulties. So, an alcoholic might be able to say ‘I have used alcohol to cope with my problems, but I know that is not the only way. Others before me have quit drinking. I can too, with the right support.’

Sometimes, people may not be aware that they are having certain thoughts, or how much the thoughts are bringing them down. So, cognitive therapy usually involves a lot of problem-solving. This can be helped by models such as the ‘hot cross bun‘.

The ‘hot cross bun’ model gives individuals a space to fill in exactly where their thoughts, feelings, behaviors and physical sensations might be reinforcing one another in specific situations. For example, getting stressed (feelings and physical sensations) at work (situation) might lead someone to have a cigarette (behavior). This might make them feel guilty and sad (more feelings), and perhaps also sick and breathless (physical sensations). This reinforces an automatic thought in the person that they are bad and unhealthy. This makes them stressed, which may prompt more smoking.

Complicated, right? CBT is all about breaking down these cycles and turning them around. This process might look very different for each person.

For one person, CBT techniques might include more behavioral elements. They might develop alternative coping skills to deal with stress and prevent other unhealthy ways of coping. For another, CBT might be more about directly questioning thinking patterns to increase motivation and self-esteem.

Change might take place in therapy sessions, psycho-education groups or through a self-help book or mobile app.

This idea of emotions, thoughts and actions being linked might sound rather obvious to lots of us in this emotionally literate age. But, at the time, Aaron Beck had outlined a very important ethos for the future of psychotherapy.

The history of cognitive-behavioral therapy

Our friend Sigmund Freud had already introduced the concept of a ‘talking cure‘ back in the early 20th century. Freud believed that depressed (or what he called ‘hysterical’) patients were largely victims of their unconscious beliefs and fears. Freud used psychoanalytic methods, including asking patients about their childhood relationships, to determine what these unconscious drives might be.

There is a lot to be said for Freud’s work. He changed the way that the world viewed mental illness by arguing that problems should be talked about with a professional, rather than locked behind closed doors.

Freud also emphasised the importance of self-reflection: in terms of becoming aware of our own complicated psyche in order to figure out current emotional and behavioral difficulties.

However, psychotherapists like Freud may have used patients more as a reflection for their own ideals and theories (particularly those about sex). Vulnerable people were often at the mercy of the psychotherapist. They might spend years in therapy as subjects for case studies, without much personal gain.

Modern psychotherapy, including psychoanalysis and CBT, involves more of a collaborative approach between the patient and the therapist. There is an emphasis on the ability of most individuals to reflect and problem-solve about their personal difficulties. The therapist provides guidance, but all of the power to change is given to the patient. After all, who knows you better than you?

The beginnings of respect for patient choice and autonomy can be accredited to the work of Beck and many of the other early CBT therapists. Beck wasn’t the first to pinpoint the relationship between thoughts and emotions. Albert Ellis came up with rational-emotive behavior therapy in the 1950s, which laid the groundwork for Beck’s ideas about questioning beliefs to change emotions and behavior.

Ellis believed that individuals had the power to question their own assumptions about the world. These ideas are employed in modern CBT, where individuals are encouraged to challenge problematic self-talk such as ‘I should be competent at everything’.

Ellis also theorized the ABC technique of irrational beliefs. This model suggests activating events (A) provoke negative beliefs (B) and cause adverse consequences (C) for the individual. For example, someone might experience a traumatic accident. This might lead them to believe the world is an unsafe place. This might then cause them to feel constantly afraid and take up problematic habits that help them avoid these thoughts and feelings.

Modern CBT therapists often encourage individuals to consider why they might have certain beliefs. However, CBT is more efficient and time-limited than psychoanalysis and tends to focus more on current problems.

Why is CBT so credible?

One of the reasons that CBT is so respected in psychology today is that it is time-limited. Resources in health settings are stretched and scarce. Consequently, effective treatment that can be condensed into short-term interventions is largely welcomed by health professionals. Psychologists are increasingly adopting CBT as their specialism. Nurses and support workers can also be easily trained to deliver CBT techniques, doubling its efficiency in multi-disciplinary health settings.

This efficiency also means that a lot of funding has been invested in research about the efficacy of CBT. Reviews and evaluations indicate that CBT is a consistently effective and acceptable intervention across several populations. For example, the evidence shows that people with many types of anxiety disorder can benefit from CBT.

Importantly, CBT through self-help or electronic mediums has been shown to be effective. More research in this area could take a huge burden on health services.

Apart from being efficient and effective, CBT is also very malleable. It can be combined with other treatment plans such as acceptance and commitment therapy (ACT) or dialectical behavior therapy (DBT). This makes CBT treatment highly progressive.

The key to the success of CBT mostly lies with the individual. It takes a lot of effort to question your entire belief system and make big changes to behavior. CBT treatment is typically most effective when patients apply what they learn in therapy sessions in their own time. This is why therapists will often set homework assignments and weekly goals for patients.

What can CBT be useful for?

CBT treatment has been adapted to accommodate countless mental health difficulties: obsessive-compulsive disorder, borderline personality disorder and social anxiety all have established CBT treatment plans.

CBT techniques are also increasingly employed in interventions that help people with physical health problems. Cancer patients or people suffering from chronic pain can benefit tremendously from the coping skills taught in CBT treatment approaches.

Illness is a prime example of one of the ‘activating events’ that Ellis talked about in his ABC model. It can generate understandable but unhelpful health beliefs such as ‘I am just an ill person’ or ‘no-one should be in pain for this long’. Challenging these beliefs can really make a difference for somebody who is already having a hard time in life.

CBT skills are built on such fundamental principles that they can be useful for most problems. We all have some beliefs that don’t serve us well in life. We all have bad moods. We all struggle to stay motivated sometimes. Perspective and self-reflection can make the world of difference.

Where can I get CBT from?

Since CBT has such a good evidence base, many mental health services do offer it as an intervention. However, waiting lists can be long.

The good news is that researchers are constantly coming up with novel ways to enable people to learn CBT skills without waiting on a list. Targeted web-based and smartphone-based CBT support are becoming increasingly available. For example, the Quit Genius app is a very convenient way to learn to manage and overcome an addiction to smoking. The app teaches key skills like self-reflection and goal-setting. It also enables users to question common health beliefs and misconceptions to reach their goals.

Please note here that face-to-face support from a professional may be more advisable for individuals suffering from severe and enduring emotional health issues.

Take home message

So, what have we learned? Well, the evidence shows that CBT is a highly effective intervention for an endless list of physical and mental health problems. The key principles of addressing and re-writing the complex relationships between our thoughts, feelings and emotions are fundamental to the success of CBT over the past sixty-plus years. These skills are transferable and can benefit pretty much anyone looking to make positive changes in their life if they are willing to put in the work.

CBT-based support can be found through a number of mediums. You can work in collaboration with a CBT therapist or through the medium of a book, website or mobile app.

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