What is CBT? Defining Cognitive-Behavioral Therapy

Cognitive-Behavioral Therapy (CBT) is the preferred treatment for many mental health disorders, enabling therapists to help clients quickly reduce suffering and improve and maintain their wellbeing (Beck, 2011).

The CBT model builds on the idea that a realistic evaluation of our thinking can improve our emotional state and behavior. It has proven so popular that its scope now includes a wide variety of applications across diverse peoples and cultures.

Crucially, extensive trials and research continue to confirm its effectiveness in treating clients in therapy (Beck, 2011; Dobson & Dozois, 2021).

This article explores what we mean when we ask, ‘What is CBT?’

Before you continue, we thought you might like to download our three Positive CBT Exercises for free. These science-based exercises will provide you with detailed insight into Positive CBT and give you the tools to apply it in your therapy or coaching.

What Is the Meaning of CBT? An Overview

In the 1960s, therapist Aaron T. Beck set out to prove that the theories behind psychoanalysis–and the treatment of depression in particular–were empirically valid. And yet, what he found was not in line with what he expected. Instead, he “identified distorted, negative cognition (primarily thoughts and beliefs) as a primary feature of depression” (Beck, 2011, p. 1).

Rather than ignore the findings, his response was to commit to developing a short-term treatment to test and challenge the reality of patients’ depressed thinking.

And so began ‘cognitive therapy,’ now more usually referred to as Cognitive Behavior Therapy (CBT), and its transformation of psychotherapy.

This cognitive model proposes that dysfunctional thinking is behind all psychological disturbances (Beck, 2011).

And while there are now several approaches within the scope of CBT, they all share the theoretical view that (modified from Dobson & Dozois, 2021, p. 6):

• Internal covert processes called thinking or cognition occur
• Cognition influences how a person feels and behaves
• That person can alter their cognition to mediate behavior change.

The cognitive-behavioral therapist endeavors to understand their clients’ beliefs and behavioral patterns and then uses that knowledge to produce cognitive, emotional, and behavioral change by modifying their thinking and belief system (Beck, 2011).

Treatments focus on the processes of cognition, cognitive reappraisal, behavior change, and emotional regulation to reduce distress, improve functioning, benefit quality of life, and enhance wellbeing (Kazantzis et al., 2018).

How Does Cognitive-Behavioral Therapy Work?

It is important to note that CBT is not done to the client but is collaborative, relying on trust, openness, and a solid therapeutic alliance.

Clients learn to evaluate their thinking more realistically and adaptively, identifying automatic thoughts, such as ‘Whenever I try something new, it goes wrong’ or ‘Nobody likes me’ (Beck, 2011).

Such unhelpful thinking typically leaves the client feeling sad or frustrated (negative emotions) and causes them to avoid new experiences (negative or damaging behavior) rather than embrace opportunities for growth and development (Beck, 2011).

If the client is encouraged to validate the idea, possibly reviewing past experiences, they may find the opposite is true. While things do sometimes go wrong, many of their attempts to take part in novel situations have, in fact, created positive experiences (Beck, 2011).

While there are several major approaches in CBT, they work by adopting the following three fundamental propositions (modified from Dobson & Dozois, 2021, p. 4):

1. Our cognitive activity (thought processes) affects our behavior
2. Such cognitive activity can be monitored and altered
3. Cognitive change can lead to desired behavioral change

Put simply, CBT works because the modification of clients’ “underlying dysfunctional beliefs produces more enduring change” (Beck, 2011, p. 3).

How CBT changes the brain

CBT has undergone a great deal of testing by the scientific community. Research suggests the treatment is effective for a broad range of psychological disorders, problems, and even medical problems with underlying psychological components (Beck, 2011).

A 2018 meta-analysis of research into the efficacy of CBT provides additional support for its ability to change cognitive processes, implement beneficial behavioral strategies, and support emotional regulation (Kazantzis et al., 2018).

A recent study into CBT’s ability to treat chronic pain suggests that cognitive therapy reduces catastrophizing and displays associated changes to brain activation and functional connectivity as identified by functional MRI scans. Their findings show that “CBT reduces potentially dysfunctional brain states,” normalizing processing and connections across multiple areas of the brain, including the “insula cortex and primary somatosensory regions” (Lazaridou et al., 2017, p. 8).

CBT vs DBT vs ACT

The “first wave” of behavioral therapies refers to behaviorism, including operant and classical conditioning; the “second wave” includes the introduction of CBT—recognizing the importance of the individual’s thoughts and beliefs in their behavior and emotional experiences (Beck, 2011; Dobson & Dozois, 2021).

Third wave CBTs go further, prioritizing psychological and behavioral processes tied in with health and wellbeing over reducing and eliminating psychological and emotional symptoms. They focus on how the person relates to internal experiences, adding to, rather than necessarily replacing, more traditional techniques (Dobson & Dozois, 2021).

As part of the ‘third wave” it is helpful to consider two of the newer therapies, dialectical behavior therapy (DBT) and acceptance and commitment therapy (ACT).

Dialectical Behavior Therapy (DBT)

While DBT originally evolved from CBT to treat self-injuring and suicidal clients with borderline personality disorder, it is now used in various settings to treat multiple problem behaviors (Dobson & Dozois, 2021).

Composed of multiple behavioral, cognitive, and mindfulness-based strategies, DBT balances acceptance and change while promoting dialectical thinking. Rather than denying or rejecting reality, the individual accepts things ‘as they are’ and focuses their attention on the present moment without judgment (Dobson & Dozois, 2021).

Clients are taught the necessary skill sets (mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance) in a group setting, emphasizing how to apply and practice the skills successfully.

Acceptance Commitment Therapy (ACT)

While cognitive-based therapy often successfully treats anxiety and other such conditions, “partial or full return of anxiety following traditional CBT is more common than many of us would like to believe” (Forsyth & Eifert, 2016, p. 8).

CBT assumes that you will become happier and thrive by changing how you think and feel, yet getting anxiety (or other such feelings) under control does not guarantee a better life.

In contrast, ACT suggests that our thoughts and feelings may not be the enemy and encourages individuals to bring acceptance and compassion to unpleasant and uncomfortable thoughts (Forsyth & Eifert, 2016).

The focus is on metacognitive processes – the worry about worry – and becoming more aware of the process surrounding how we appraise our thoughts, emotions, and events. Rather than attempting to make a cognitive or behavioral change, ACT encourages an acceptance of the distress and recognition and commitment to respond to it (Dobson & Dozois, 2021; Forsyth & Eifert, 2016).

Conditions CBT Can Be Effective For

The cognitive-behavioral approach “has been applied to many specific clinical populations, each emphasizing different features of the same core model” (Kazantzis et al., 2018, p. 349).

Here are examples of specific applications, with the research to confirm its relevance:

CBT for Anxiety

Fear and anxiety are part of normal development for most children, and while its focus evolves as perceptions of reality change, it continues into adulthood (Dobson & Dozois, 2021).

And yet, “anxiety becomes a disorder when the experience is exaggerated beyond that which would be expected in a given situation” or when it interferes with the individual’s functioning (Dobson & Dozois, 2021, p. 360).

Anxious clients often engage in avoidance (for example, spending extra time in bed or, more subtly, avoiding eye contact), sometimes described as safety behaviors. CBT can help by identifying activities and environments that expose them to their fears and gradually introducing them into their daily activities.

Frequent exposure and slowly increasing their intensity, combined with relaxation techniques, and identifying and replacing automatic and unhelpful thoughts, can reduce discomfort over time (Beck, 2011).

CBT for Depression

CBT treatments have been shown to provide “more rapid and complete relief of depressive symptoms” than some other therapies, including systemic-behavioral family therapy and nondirective supportive therapy (Dobson & Dozois, 2021, p. 367).

A large study of youths with depression found that CBT–including psychoeducation, goal setting, cognitive restructuring, and problem-solving was most effective when combined with drug treatments (Dobson & Dozois, 2021).

A 2018 meta-analysis of studies found CBT to have effect sizes ranging “from small to large for modifying cognitive processes and reductions in dysfunctional thinking” (Kazantzis et al., 2018, p. 353).

While CBT clearly has a positive effect on treating clients with depression, more research is required to understand better how we can combine it with other treatments.

CBT for Insomnia

Insomnia is one of the most widespread, and yet often neglected, conditions experienced by the general and psychiatric populations, with a severe impact on the sufferer’s wellbeing (Bhaskar, Hemavathy, & Prasad, 2016).

Research shows CBT to be particularly helpful in therapy for those experiencing sleep issues, improving sleep efficacy, reducing sleep medications, cutting the time taken to fall asleep, and increasing sleep duration. Crucially, CBT can, if required, be combined with other treatments, including pharmaceutical ones, with individuals reporting significant improvements in their sleep quality (Dobson & Dozois, 2021).

CBT for OCD

Studies suggest that CBT techniques (particularly behavioral ones) and pharmacology result in significant decreases in Obsessive-Compulsive Disorder (OCD) symptoms, and this effect increases when combined. CBT appears helpful in both the tolerance of distress and reducing dysfunctional beliefs (Dobson & Dozois, 2021).

When clients have obsessive thoughts, for which rational evaluation is ineffective, CBT practitioners may find it helpful to encourage clients to label and accept their experiences. This can help them refocus, turning their attention to the road ahead (Beck, 2011).

CBT for Trauma

People experiencing a “traumatic event can develop associations among objectively safe reminders of the event” (such as loud noises, news stories), concluding that the world is a dangerous place and responding with fear, anxiety, or numbing of feelings (APA, 2017, para. 4).

If individuals incorporate trauma into their beliefs about themselves and the world, they may begin to form unhelpful (and incorrect) understandings. For example, after a robbery or a violent attack, they may conclude that, in some way, they deserved it (APA, 2017).

CBT can help by working with the client to identify and replace unhelpful thoughts and beliefs with more positive ones. It encourages clients to see themselves as survivors rather than victims, seek support from loved ones, and feel capable of coping and managing feelings (Anxiety & Depression Association of America, 2017).

CBT for PTSD

Post-traumatic stress disorder (PTSD) is related to trauma but is not the same. “A traumatic event is time-based, while PTSD is a longer-term condition where one continues to have flashbacks and re-experiencing the traumatic event” (Anxiety & Depression Association of America, 2017, para. 4).

The American Psychological Association (APA) recognizes that CBT can help reduce symptoms associated with PTSD by using cognitive and behavioral techniques to reduce symptoms and improve functioning. Therapists help clients re-evaluate thoughts and beliefs to overcome distortions and reach more effective and balanced thinking patterns (APA, 2017).

Overall, psychoeducation on the processes surrounding PTSD can benefit clients’ ability to manage their stress and plan for future crises or difficult situations (APA, 2017).

CBT for ADHD

Children (and adults) diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD) typically have higher levels of inattention, impulsivity, and hyperactivity, possibly linked to cognitive deficiencies (Dobson & Dozois, 2021).

Despite the potential match between the needs of children with ADHD and the goals of CBT, a growing body of research suggests that CBT has a limited effect on youths with ADHD and yet, combined with drug therapies, may still be more effective than medication alone (Dobson & Dozois, 2021, p. 366).

Attending CBT Online: Does It Work?

CBT has proven helpful across a wide range of settings outside the typical face-to-face interaction between therapist and client, including online, group, and community settings (Beck, 2011).

Using powerful tools, such as Quenza, that support online therapy and coaching, increasing client engagement, managing homework, and remote consultations between therapists and clients can significantly enhance treatment using CBT (and other therapy) techniques.

The power and potential of online CBT are highlighted in a 2021 review of internet-based CBT (iCBT) to treat depression. While findings showed that guided CBT had a greater effect than unguided, both were successful at reducing the symptoms of depression.

Furthermore, “personalized treatment selection is entirely possible and necessary to ensure the best allocation of treatment resources for depression” (and other disorders) (Karyotaki et al., 2021, p. 361).

PositivePsychology.com’s CBT Resources

We have numerous resources available for therapists wishing to adopt tools and techniques from CBT to help their clients.

Why not download our free CBT pack and try out the powerful tools contained within, including:

• Strength Spotting by Exception Finding
  Solution-focused therapy supports clients as they identify what was different when a problem was absent. This worksheet focuses on the who, what, when, and where of exception, rather than problem times.
• Reframing Critical Self-Talk
  Self-criticism can be harmful. This exercise helps clients to reduce its frequency and impact by softening their critical voice.

Other free resources include:

• A Simple Thought Diary
  Capturing and later evaluating our thoughts can be a valuable starting point for challenging and, in time, changing our thought patterns.
• If-then Planning Worksheet
  Visualizing scenarios can help us plan for challenges and obstacles before they arise.

More extensive versions of the following tools are available with a subscription to the Positive Psychology Toolkit©, but they are described briefly below:

• The Most Helpful Thoughts
  Many psychological problems develop because of inaccurate and unhelpful ways of thinking. This exercise helps clients identify such unhelpful thoughts and formulate more helpful ones in any given situation:
  • Identifying unhelpful thoughts
  • Analyzing the helpfulness of thoughts
  • Identify more helpful thoughts
  • Reflecting on such helpful thoughts
• Diary of Better Moments
  Our use of positive and negative information to make sense of our surroundings is imbalanced.

This exercise will help clients develop a more balanced perspective by focusing on and recording the everyday things that turn out better than or not as bad as expected.

Once captured, they can be reviewed and reflected upon while looking for common threads and recognizing how the client felt during their better moments.

If you’re looking for more science-based ways to help others through CBT, this collection contains 17 validated positive CBT tools for practitioners. Use them to help others overcome unhelpful thoughts and feelings and develop more positive behaviors.

A Take-Home Message

CBT has dramatically and positively affected the lives of many clients with mental health issues and disorders, becoming one of the most dominant talking therapy treatments.

Combining multiple techniques and practices in-session and as homework can help clients rapidly reduce suffering and improve their mental wellbeing.

CBT is collaborative, building on a trusting and robust therapeutic bond between therapist and client, supporting the latter as they learn to identify unrealistic and unhelpful thoughts and replace them with more helpful ones.

Underpinned by research studies and clients’ positive experiences, CBT offers valuable tools for effectively treating a broad range of psychological disorders and health problems with a psychological component, including chronic pain, anxiety, depression, insomnia, OCD, trauma, and PTSD.

Treatment appears to affect the brain directly, normalizing processing and connections across multiple areas, as clients recognize the importance of their thoughts and beliefs in their behavior and emotional experiences.

Undoubtedly, CBT offers a well-validated approach for mental health professionals helping clients face issues that directly impact their and others’ lives, whether implemented in face-to-face, online, or group settings.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free.